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— Each of the numbered items is followed by lettered answers. Select the ONE lettered answer that is BEST in each case. cH — ~~ = wy £ wn Item 1 On physical examination, there is a1.8-cm firm mass in 72) a the upper outer left breast. There is no axillary or supracla- nn A 58-year-old woman is evaluated for a 6-week history of wn vicular adenopathy. fatigue, anorexia, and abdominal distention. She has lost = Complete blood count and comprehensive metabolic a 2.3 kg (5 Ib) over the past week. For the past 4 days, she (-F) profile, including alkaline phosphatase level, are normal. rn has been so debilitated that she has difficulty ambulating Mammogram and ultrasound confirm a 1.8-cm mass in due to abdominal pain and fatigue; she has been bedbound the left upper outer breast. for the past 48 hours. Prior to this, she had been working Core biopsy of the left breast reveals estrogen receptor- full time and running approximately 12 miles per week. negative, progesterone receptor-negative, and human epi- Medical history is otherwise unremarkable, and she takes dermal growth factor receptor 2—-negative invasive ductal no medications. carcinoma. On physical examination, vital signs are normal. Abdominal examination reveals distention with normal bowel sounds. The liver edge is palpable 4 cm below the Which of the following is the most appropriate pretreatment right costal margin. Stool sample is guaiac-positive. imaging for this patient?

= wy £ wn Item 1 On physical examination, there is a1.8-cm firm mass in 72) a the upper outer left breast. There is no axillary or supracla- nn A 58-year-old woman is evaluated for a 6-week history of wn vicular adenopathy. fatigue, anorexia, and abdominal distention. She has lost = Complete blood count and comprehensive metabolic a 2.3 kg (5 Ib) over the past week. For the past 4 days, she (-F) profile, including alkaline phosphatase level, are normal. rn has been so debilitated that she has difficulty ambulating Mammogram and ultrasound confirm a 1.8-cm mass in due to abdominal pain and fatigue; she has been bedbound the left upper outer breast. for the past 48 hours. Prior to this, she had been working Core biopsy of the left breast reveals estrogen receptor- full time and running approximately 12 miles per week. negative, progesterone receptor-negative, and human epi- Medical history is otherwise unremarkable, and she takes dermal growth factor receptor 2—-negative invasive ductal no medications. carcinoma. On physical examination, vital signs are normal. Abdominal examination reveals distention with normal bowel sounds. The liver edge is palpable 4 cm below the Which of the following is the most appropriate pretreatment right costal margin. Stool sample is guaiac-positive. imaging for this patient? Laboratory studies: (A) Chest radiograph and bone scan Hemoglobin 9.7 g/dL (97 g/L) (B) CT of the chest, abdomen, and pelvis Bilirubin 2.3 mg/dL (39.3 umol/L) (C) CT of the chest, abdomen, and pelvis and MRI of the Creatinine 0.9 mg/dL (79.6 umol/L) brain Contrast-enhanced CT scan demonstrates a mass in the (D) No imaging descending colon and hepatomegaly with multiple met- astatic lesions. A colonoscopy identifies a mass in the left colon, and a biopsy shows adenocarcinoma. Item 4 A 62-year-old man is evaluated for adjuvant therapy after Which of the following is the most appropriate surgical removal of an adenocarcinoma of the colon. Post- management? surgical pathology revealed a tumor penetrating the full thickness of the colonic wall, and cancer is found in three of (A) Fluorouracil 17 lymph nodes. Presurgical imaging revealed no evidence (B) Fluorouracil and oxaliplatin of distant metastatic disease. (C) Hemicolectomy (D) Supportive, comfort-oriented care Which of the following is the most appropriate adjuvant treatment?

Laboratory studies: (A) Chest radiograph and bone scan Hemoglobin 9.7 g/dL (97 g/L) (B) CT of the chest, abdomen, and pelvis Bilirubin 2.3 mg/dL (39.3 umol/L) (C) CT of the chest, abdomen, and pelvis and MRI of the Creatinine 0.9 mg/dL (79.6 umol/L) brain Contrast-enhanced CT scan demonstrates a mass in the (D) No imaging descending colon and hepatomegaly with multiple met- astatic lesions. A colonoscopy identifies a mass in the left colon, and a biopsy shows adenocarcinoma. Item 4 A 62-year-old man is evaluated for adjuvant therapy after Which of the following is the most appropriate surgical removal of an adenocarcinoma of the colon. Post- management? surgical pathology revealed a tumor penetrating the full thickness of the colonic wall, and cancer is found in three of (A) Fluorouracil 17 lymph nodes. Presurgical imaging revealed no evidence (B) Fluorouracil and oxaliplatin of distant metastatic disease. (C) Hemicolectomy (D) Supportive, comfort-oriented care Which of the following is the most appropriate adjuvant treatment? Item 2 (A) Bevacizumab

Laboratory studies: (A) Chest radiograph and bone scan Hemoglobin 9.7 g/dL (97 g/L) (B) CT of the chest, abdomen, and pelvis Bilirubin 2.3 mg/dL (39.3 umol/L) (C) CT of the chest, abdomen, and pelvis and MRI of the Creatinine 0.9 mg/dL (79.6 umol/L) brain Contrast-enhanced CT scan demonstrates a mass in the (D) No imaging descending colon and hepatomegaly with multiple met- astatic lesions. A colonoscopy identifies a mass in the left colon, and a biopsy shows adenocarcinoma. Item 4 A 62-year-old man is evaluated for adjuvant therapy after Which of the following is the most appropriate surgical removal of an adenocarcinoma of the colon. Post- management? surgical pathology revealed a tumor penetrating the full thickness of the colonic wall, and cancer is found in three of (A) Fluorouracil 17 lymph nodes. Presurgical imaging revealed no evidence (B) Fluorouracil and oxaliplatin of distant metastatic disease. (C) Hemicolectomy (D) Supportive, comfort-oriented care Which of the following is the most appropriate adjuvant treatment? Item 2 (A) Bevacizumab A 65-year-old man is evaluated for a single episode of pain- (B) Capecitabine less gross hematuria that occurred 1 month ago. Medical (C) Oxaliplatin, fluorouracil, and leucovorin (FOLFOX) history is notable only for atrial fibrillation managed with (D) Radiation therapy metoprolol and rivaroxaban. (E) No additional therapy On physical examination, vital signs are normal. Car- diac examination reveals an irregularly irregular rhythm. Urinalysis is normal. Item 5 Ultrasound of the kidneys and bladder is normal. A 68-year-old man is evaluated for early satiety and right upper quadrant discomfort. He is otherwise well. He reports Which of the following is the most appropriate that he is still working full time and walks about a half mile management? to and from work each day. > ) Cystoscopy On physical examination, vital signs are normal. Exam- ination is notable for hepatomegaly. Repeat urinalysis in 1 week Complete blood count is normal. On serum chemis- Substitute warfarin for rivaroxaban try testing, alkaline phosphatase and aminotransferase Urine cytology levels are elevated; bilirubin and creatinine levels are fs Reassurance and no additional intervention normal. CT scan of the chest, abdomen, and pelvis shows hep- atomegaly with multiple metastatic lesions and abdominal Item 3 carcinomatosis with a small amount of ascites. No other A 52-year-old woman is evaluated in the office for a left abnormalities are noted. Liver biopsy reveals adenocarci- breast lump that developed 3 months ago. She is asymp- noma.

A 65-year-old man is evaluated for a single episode of pain- (B) Capecitabine less gross hematuria that occurred 1 month ago. Medical (C) Oxaliplatin, fluorouracil, and leucovorin (FOLFOX) history is notable only for atrial fibrillation managed with (D) Radiation therapy metoprolol and rivaroxaban. (E) No additional therapy On physical examination, vital signs are normal. Car- diac examination reveals an irregularly irregular rhythm. Urinalysis is normal. Item 5 Ultrasound of the kidneys and bladder is normal. A 68-year-old man is evaluated for early satiety and right upper quadrant discomfort. He is otherwise well. He reports Which of the following is the most appropriate that he is still working full time and walks about a half mile management? to and from work each day. > ) Cystoscopy On physical examination, vital signs are normal. Exam- ination is notable for hepatomegaly. Repeat urinalysis in 1 week Complete blood count is normal. On serum chemis- Substitute warfarin for rivaroxaban try testing, alkaline phosphatase and aminotransferase Urine cytology levels are elevated; bilirubin and creatinine levels are fs Reassurance and no additional intervention normal. CT scan of the chest, abdomen, and pelvis shows hep- atomegaly with multiple metastatic lesions and abdominal Item 3 carcinomatosis with a small amount of ascites. No other A 52-year-old woman is evaluated in the office for a left abnormalities are noted. Liver biopsy reveals adenocarci- breast lump that developed 3 months ago. She is asymp- noma. tomatic. Medical history is unremarkable, and she takes no The patient is diagnosed with metastatic cancer from an medications. unknown primary.

A 65-year-old man is evaluated for a single episode of pain- (B) Capecitabine less gross hematuria that occurred 1 month ago. Medical (C) Oxaliplatin, fluorouracil, and leucovorin (FOLFOX) history is notable only for atrial fibrillation managed with (D) Radiation therapy metoprolol and rivaroxaban. (E) No additional therapy On physical examination, vital signs are normal. Car- diac examination reveals an irregularly irregular rhythm. Urinalysis is normal. Item 5 Ultrasound of the kidneys and bladder is normal. A 68-year-old man is evaluated for early satiety and right upper quadrant discomfort. He is otherwise well. He reports Which of the following is the most appropriate that he is still working full time and walks about a half mile management? to and from work each day. > ) Cystoscopy On physical examination, vital signs are normal. Exam- ination is notable for hepatomegaly. Repeat urinalysis in 1 week Complete blood count is normal. On serum chemis- Substitute warfarin for rivaroxaban try testing, alkaline phosphatase and aminotransferase Urine cytology levels are elevated; bilirubin and creatinine levels are fs Reassurance and no additional intervention normal. CT scan of the chest, abdomen, and pelvis shows hep- atomegaly with multiple metastatic lesions and abdominal Item 3 carcinomatosis with a small amount of ascites. No other A 52-year-old woman is evaluated in the office for a left abnormalities are noted. Liver biopsy reveals adenocarci- breast lump that developed 3 months ago. She is asymp- noma. tomatic. Medical history is unremarkable, and she takes no The patient is diagnosed with metastatic cancer from an medications. unknown primary. 53

Self-Assessment Test rn @o = Which of the following is the most appropriate On physical examination, vital signs are normal. Pelvic BT Ww management? examination reveals a bulky and friable cervical mass with m) @o extension to the lower third of the vagina. The remainder of wn (A) Measure serum CA-19-9, CA-15-3, and CA-125 antigens ) the examination is normal. 3 (B) Obtain a gene expression array Biopsy of the cervical mass reveals squamous cell car- @ = (C) PET cinoma. CT scan of the abdomen and pelvis reveals a large -r (D) Upper endoscopy, wireless capsule endoscopy, and cervical mass with extension to the pelvic sidewall and o wn colonoscopy pelvic adenopathy. rr (E) No additional testing; initiate combination chemo- therapy Which of the following is the most appropriate treatment for this patient?

rn @o = Which of the following is the most appropriate On physical examination, vital signs are normal. Pelvic BT Ww management? examination reveals a bulky and friable cervical mass with m) @o extension to the lower third of the vagina. The remainder of wn (A) Measure serum CA-19-9, CA-15-3, and CA-125 antigens ) the examination is normal. 3 (B) Obtain a gene expression array Biopsy of the cervical mass reveals squamous cell car- @ = (C) PET cinoma. CT scan of the abdomen and pelvis reveals a large -r (D) Upper endoscopy, wireless capsule endoscopy, and cervical mass with extension to the pelvic sidewall and o wn colonoscopy pelvic adenopathy. rr (E) No additional testing; initiate combination chemo- therapy Which of the following is the most appropriate treatment for this patient? (A) Concurrent radiation therapy and cisplatin Item 6 (B) Hysterectomy and pelvic node dissection A 52-year-old man is seen following an axillary lymph node (C) Radiation therapy biopsy confirming a diagnosis of large B-cell lymphoma. Complete blood count, liver chemistry tests, and (D) Radiation therapy and pembrolizumab electrolyte, blood urea nitrogen, and creatinine levels are normal. PET/CT shows uptake in left axillary, mediastinal, Item 9 hilar, and retroperitoneal nodes, as well as multiple foci in A 64-year-old man is evaluated in the emergency depart- the ileum, ribs, and vertebral bodies. ment for 5 days of increasing bouts of diarrhea. He was diagnosed with metastatic melanoma 2 months ago and Which of the following is the most appropriate staging test has received three doses of immunotherapy with ipilim- to perform next? umab and nivolumab. He was seen 3 days ago for diarrhea (two loose stools daily). Evaluation for infectious causes of (A) Bone marrow biopsy diarrhea, including Clostridioides difficile, was initiated, (B) Brain MRI and loperamide was begun. Today he reports increased (C) CT-guided biopsy of retroperitoneal lymph node diarrhea, with up to five loose stools per day. He takes no (D) Serum lactate dehydrogenase measurement additional medications. On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 95/70 mm Hg, and pulse rate is Item 7 100/min. Abdomen is slightly tender and distended without A 54-year-old woman is evaluated for a several-month hepatosplenomegaly. history of increasing abdominal girth. Medical history is Complete blood count, metabolic panel, and thyroid- otherwise unremarkable, and she takes no medications. stimulating hormone level are normal, and stool studies, On physical examination, vital signs are normal. including nucleic acid amplification testing for Clostridioides Abdominal examination reveals ascites. Pelvic examination difficile toxin genes, are negative. Fecal calprotectin and and the remainder of the physical examination are normal. fecal lactoferrin levels are elevated. Complete blood count and comprehensive metabolic Ipilimumab and nivolumab are discontinued. The profile are normal. patient is admitted to the hospital for intravenous fluids

(A) Concurrent radiation therapy and cisplatin Item 6 (B) Hysterectomy and pelvic node dissection A 52-year-old man is seen following an axillary lymph node (C) Radiation therapy biopsy confirming a diagnosis of large B-cell lymphoma. Complete blood count, liver chemistry tests, and (D) Radiation therapy and pembrolizumab electrolyte, blood urea nitrogen, and creatinine levels are normal. PET/CT shows uptake in left axillary, mediastinal, Item 9 hilar, and retroperitoneal nodes, as well as multiple foci in A 64-year-old man is evaluated in the emergency depart- the ileum, ribs, and vertebral bodies. ment for 5 days of increasing bouts of diarrhea. He was diagnosed with metastatic melanoma 2 months ago and Which of the following is the most appropriate staging test has received three doses of immunotherapy with ipilim- to perform next? umab and nivolumab. He was seen 3 days ago for diarrhea (two loose stools daily). Evaluation for infectious causes of (A) Bone marrow biopsy diarrhea, including Clostridioides difficile, was initiated, (B) Brain MRI and loperamide was begun. Today he reports increased (C) CT-guided biopsy of retroperitoneal lymph node diarrhea, with up to five loose stools per day. He takes no (D) Serum lactate dehydrogenase measurement additional medications. On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 95/70 mm Hg, and pulse rate is Item 7 100/min. Abdomen is slightly tender and distended without A 54-year-old woman is evaluated for a several-month hepatosplenomegaly. history of increasing abdominal girth. Medical history is Complete blood count, metabolic panel, and thyroid- otherwise unremarkable, and she takes no medications. stimulating hormone level are normal, and stool studies, On physical examination, vital signs are normal. including nucleic acid amplification testing for Clostridioides Abdominal examination reveals ascites. Pelvic examination difficile toxin genes, are negative. Fecal calprotectin and and the remainder of the physical examination are normal. fecal lactoferrin levels are elevated. Complete blood count and comprehensive metabolic Ipilimumab and nivolumab are discontinued. The profile are normal. patient is admitted to the hospital for intravenous fluids Contrast-enhanced CT scan of the chest, abdomen, and and additional treatment. pelvis reveals ascites with areas of peritoneal and omental thickening consistent with metastatic cancer. No abnormal- Which of the following is the most appropriate additional ities of the liver are noted, and the adnexa appear normal. treatment? Paracentesis is performed, and cytology reveals ade- (A) Budesonide nocarcinoma. Surgical debulking of the peritoneal tumor is planned. (B) Infliximab (C) Mesalamine Which of the following is the most appropriate adjuvant (D) Methylprednisolone management?

Contrast-enhanced CT scan of the chest, abdomen, and and additional treatment. pelvis reveals ascites with areas of peritoneal and omental thickening consistent with metastatic cancer. No abnormal- Which of the following is the most appropriate additional ities of the liver are noted, and the adnexa appear normal. treatment? Paracentesis is performed, and cytology reveals ade- (A) Budesonide nocarcinoma. Surgical debulking of the peritoneal tumor is planned. (B) Infliximab (C) Mesalamine Which of the following is the most appropriate adjuvant (D) Methylprednisolone management? (A) Chemotherapy with a gastrointestinal cancer regimen Item 10 (B) Chemotherapy with ovarian cancer regimen A 79-year-old man is evaluated in the office following a (C) Immunotherapy with a programmed death receptor 1 recent hospitalization for pneumonia. This is his second inhibitor episode of pneumonia in the past year. Medical history (D) Total abdominal irradiation is notable for chronic lymphocytic leukemia. His disease course has been followed without treatment for the past 9 years. Item 8 On physical examination, vital signs are normal. Pul- A 45-year-old woman is evaluated after experiencing lower monary examination is normal. There is diffuse adenopathy pelvic pain and heavy vaginal bleeding. and splenomegaly. 54

Self-Assessment Test bee Laboratory studies: (C) Initiate chemotherapy @ im Leukocyte count 46,000/uL (46 x 10°/L) with 92% sot (D) Initiate endocrine-based therapy tJ lymphocytes, 6% neutrophils, 1% 5) bands, and 1% monocytes = wn IgG 320 mg/dL (3.2 g/L) Item 13 rn (<5) 172) IgA 20 mg/dL (0.2 g/L) A 71-year-old woman is evaluated for metastatic colon wn”

bands, and 1% monocytes = wn IgG 320 mg/dL (3.2 g/L) Item 13 rn (<5) 172) IgA 20 mg/dL (0.2 g/L) A 71-year-old woman is evaluated for metastatic colon wn” IgM 34 mg/dL (0.34 g/L) Pd cancer. Stage III colon cancer was diagnosed and treated = with surgery and adjuvant chemotherapy 3 years ago. The +8) Which of the following is the most appropriate treatment rn tumor was found to be mismatch repair-deficient. Eval- for this patient? uation for a germline mismatch repair protein deficiency (A) Granulocyte-colony stimulating factor (Lynch syndrome) was negative. Six months ago, she was (B) Ibrutinib found to have numerous hepatic metastases and involve- ment of multiple retroperitoneal lymph nodes. She was (C) Intravenous gamma globulin treated with a standard chemotherapy regimen and was (D) Splenectomy stable for 4 months. Current CT imaging shows tumor growth in the liver and retroperitoneal lymph nodes. The patient remains asymptomatic with good performance Item 11 status. A 25-year-old man is evaluated for a 2-week history of an On physical examination, vital signs and other exam- enlarging mass in the left testicle. Medical history is unre- ination findings are normal. markable, and he takes no medications. The patient’s carcinoembryonic antigen level has On physical examination, vital signs are normal. There increased to 33.5 ug/L (normal, <5.0 ug/L). is a 3-cm, hard, left testicular mass on examination. Results of laboratory studies show an o-fetoprotein Which of the following is the most appropriate level of 2500 ng/mL (2500 ug/L) and a B-human chorionic management? gonadotropin level of 5120 IU. Ultrasound reveals a solid mass in the left testicle. CT (A) Comfort-oriented care and hospice management of the abdomen and pelvis reveals no enlargement of retro- (B) Programmed death receptor 1 inhibitor peritoneal nodes or other abnormalities. Chest radiograph (C) Stereotactic radiation therapy is normal. (D) Tyrosine kinase inhibitor

IgM 34 mg/dL (0.34 g/L) Pd cancer. Stage III colon cancer was diagnosed and treated = with surgery and adjuvant chemotherapy 3 years ago. The +8) Which of the following is the most appropriate treatment rn tumor was found to be mismatch repair-deficient. Eval- for this patient? uation for a germline mismatch repair protein deficiency (A) Granulocyte-colony stimulating factor (Lynch syndrome) was negative. Six months ago, she was (B) Ibrutinib found to have numerous hepatic metastases and involve- ment of multiple retroperitoneal lymph nodes. She was (C) Intravenous gamma globulin treated with a standard chemotherapy regimen and was (D) Splenectomy stable for 4 months. Current CT imaging shows tumor growth in the liver and retroperitoneal lymph nodes. The patient remains asymptomatic with good performance Item 11 status. A 25-year-old man is evaluated for a 2-week history of an On physical examination, vital signs and other exam- enlarging mass in the left testicle. Medical history is unre- ination findings are normal. markable, and he takes no medications. The patient’s carcinoembryonic antigen level has On physical examination, vital signs are normal. There increased to 33.5 ug/L (normal, <5.0 ug/L). is a 3-cm, hard, left testicular mass on examination. Results of laboratory studies show an o-fetoprotein Which of the following is the most appropriate level of 2500 ng/mL (2500 ug/L) and a B-human chorionic management? gonadotropin level of 5120 IU. Ultrasound reveals a solid mass in the left testicle. CT (A) Comfort-oriented care and hospice management of the abdomen and pelvis reveals no enlargement of retro- (B) Programmed death receptor 1 inhibitor peritoneal nodes or other abnormalities. Chest radiograph (C) Stereotactic radiation therapy is normal. (D) Tyrosine kinase inhibitor Which of the following is the most appropriate management? Item 14 A 62-year-old woman was diagnosed 2.5 years ago with (A) Chemotherapy left-sided, stage IIB, estrogen receptor-positive, human epi- (B) Needle biopsy of the testicular mass dermal growth factor receptor 2-negative breast cancer (C) PET/CT treated with mastectomy, postmastectomy irradiation, and (D) Radical inguinal orchiectomy letrozole, which was started 2 years ago. Medical history is otherwise unremarkable. Current medications are letro- zole, a calcium supplement, and cholecalciferol. Item 12 A 63-year-old woman is evaluated for a mass in her Which of the following is the most appropriate screening right axilla. She first noticed the mass 2 months ago. or surveillance test to perform at this time? She has also had a persistent cough. She was diagnosed (A) CT of chest, abdomen, and pelvis 3 years ago with stage IIB right breast cancer for which she underwent lumpectomy, chemotherapy, and breast (B) Dual-energy x-ray absorptiometry irradiation. (C) Echocardiogram On physical examination, vital signs are normal. There (D) Pelvic ultrasound is a firm, fixed, 2-cm mass in the right axilla. Bilateral breast examination reveals no masses or nodules. The remainder of the examination is normal. Item 15 Chest radiograph shows multiple bilateral pulmonary A 62-year-old woman undergoes follow-up evaluation for nodules. CT scan of the chest, abdomen, and pelvis shows epithelial ovarian cancer. Seven months ago, she under- new right axillary adenopathy and multiple peripheral pul- went surgical debulking with optimal cytoreduction, and monary nodules measuring up to 1.5 cm in size. There is no the primary tumor and visible metastases were all resected. hilar or mediastinal adenopathy. Surgery was followed by platinum-taxane chemotherapy. There has been no evidence of disease recurrence. Germline Which of the following is the most appropriate genetic testing revealed a BRCAI1 mutation. Her medical management? history is otherwise unremarkable, and she takes no medications. (A) Biopsy pulmonary nodule On physical examination, vital signs are normal. There (B) Biopsy right axillary mass is a well-healed laparotomy incision.

Which of the following is the most appropriate management? Item 14 A 62-year-old woman was diagnosed 2.5 years ago with (A) Chemotherapy left-sided, stage IIB, estrogen receptor-positive, human epi- (B) Needle biopsy of the testicular mass dermal growth factor receptor 2-negative breast cancer (C) PET/CT treated with mastectomy, postmastectomy irradiation, and (D) Radical inguinal orchiectomy letrozole, which was started 2 years ago. Medical history is otherwise unremarkable. Current medications are letro- zole, a calcium supplement, and cholecalciferol. Item 12 A 63-year-old woman is evaluated for a mass in her Which of the following is the most appropriate screening right axilla. She first noticed the mass 2 months ago. or surveillance test to perform at this time? She has also had a persistent cough. She was diagnosed (A) CT of chest, abdomen, and pelvis 3 years ago with stage IIB right breast cancer for which she underwent lumpectomy, chemotherapy, and breast (B) Dual-energy x-ray absorptiometry irradiation. (C) Echocardiogram On physical examination, vital signs are normal. There (D) Pelvic ultrasound is a firm, fixed, 2-cm mass in the right axilla. Bilateral breast examination reveals no masses or nodules. The remainder of the examination is normal. Item 15 Chest radiograph shows multiple bilateral pulmonary A 62-year-old woman undergoes follow-up evaluation for nodules. CT scan of the chest, abdomen, and pelvis shows epithelial ovarian cancer. Seven months ago, she under- new right axillary adenopathy and multiple peripheral pul- went surgical debulking with optimal cytoreduction, and monary nodules measuring up to 1.5 cm in size. There is no the primary tumor and visible metastases were all resected. hilar or mediastinal adenopathy. Surgery was followed by platinum-taxane chemotherapy. There has been no evidence of disease recurrence. Germline Which of the following is the most appropriate genetic testing revealed a BRCAI1 mutation. Her medical management? history is otherwise unremarkable, and she takes no medications. (A) Biopsy pulmonary nodule On physical examination, vital signs are normal. There (B) Biopsy right axillary mass is a well-healed laparotomy incision. 55

Self-Assessment Test" wn 2. ar Which of the following is the most appropriate additional uptake values in the 4 to 12 range, but 28 in the left inguinal y> wn treatment for this patient? area. wn o wn (A) Irradiation Which of the following is the most appropriate management? 3 (B) Poly (ADP-ribose) polymerase inhibitor therapy © (C) Second course of chemotherapy (A) Begin bendamustine and rituximab = ~P (D) No additional treatment (B) Begin rituximab o wn (C) Biopsy of the left inguinal nodes ona

wn 2. ar Which of the following is the most appropriate additional uptake values in the 4 to 12 range, but 28 in the left inguinal y> wn treatment for this patient? area. wn o wn (A) Irradiation Which of the following is the most appropriate management? 3 (B) Poly (ADP-ribose) polymerase inhibitor therapy © (C) Second course of chemotherapy (A) Begin bendamustine and rituximab = ~P (D) No additional treatment (B) Begin rituximab o wn (C) Biopsy of the left inguinal nodes ona (D) Radiation therapy to the left inguinal nodes Item 16 A 37-year-old woman is evaluated 6 years after completing treatment for breast cancer. She has a history of stage II estro- Item 19 gen receptor—positive/human epidermal growth factor recep- A 41-year-old woman is evaluated for a 3-month history of tor 2-positive breast cancer. She underwent lumpectomy; depressed mood nearly every day, low energy, loss of interest irradiation; chemotherapy with doxorubicin, cyclophospha- in nearly all activities, fatigue, and poor concentration. Medical mide, paclitaxel, and trastuzumab; and then completed 5 years history is significant for stage II, estrogen receptor-positive, of tamoxifen. She and her partner now want to have a child. human epidermal growth factor 2—negative breast cancer diag- nosed 2 years ago. Her only medication is tamoxifen. Which of the following risks will be increased with On physical examination, vital signs are normal. The pregnancy? remainder of the examination is unremarkable. Complete blood count, comprehensive metabolic panel, ( ) Breast cancer recurrence > and thyroid-stimulating hormone level are all normal. ( B) Breast cancer-related mortality ( ) Congenital malformations in offspring Which of the following is the most appropriate treatment? Go © ( ) No increase in congenital malformations or breast (A) Discontinue tamoxifen cancer risk (B) Prescribe bupropion (C) Prescribe fluoxetine Item 17 (D) Prescribe venlafaxine A 55-year-old woman is evaluated in the office following a recent diagnosis of metastatic adenocarcinoma of the lung. She has excellent performance status. Medical history is Item 20 otherwise unremarkable, and she takes no medications. A 56-year-old woman is evaluated for findings suspicious There are no molecular alterations (epidermal growth for inflammatory breast cancer. factor receptor, ALK, ROS1). Programmed death ligand-1 On physical examination, vital signs are normal. The expression is negative. right breast is enlarged, and the skin is thickened and ery- thematous. There is a 5- x 4-cm mass in the lower outer Which of the following is the most appropriate treatment? breast. There is an enlarged right axillary node. Right breast mammogram reveals a mass in the lower (A) Combination chemotherapy outer breast with calcifications that span approximately (B) Combination chemotherapy plus pembrolizumab 5 cm in size. Right axillary ultrasound reveals an enlarged (C) Pembrolizumab monotherapy axillary lymph node. Core biopsy of the breast reveals (D) Single-agent chemotherapy estrogen receptor-negative, progesterone receptor- negative, and human epidermal growth factor 2—negative invasive ductal carcinoma. CT of the chest, abdomen, and Item 18 pelvis and bone scan show no evidence of distant meta- static disease. A 56-year-old man is evaluated for an enlarging, painful inguinal lymph node he first noticed 1 month ago. He has a history of follicular lymphoma of 8 years’ duration. The Which of the following is the most appropriate sequence

(D) Radiation therapy to the left inguinal nodes Item 16 A 37-year-old woman is evaluated 6 years after completing treatment for breast cancer. She has a history of stage II estro- Item 19 gen receptor—positive/human epidermal growth factor recep- A 41-year-old woman is evaluated for a 3-month history of tor 2-positive breast cancer. She underwent lumpectomy; depressed mood nearly every day, low energy, loss of interest irradiation; chemotherapy with doxorubicin, cyclophospha- in nearly all activities, fatigue, and poor concentration. Medical mide, paclitaxel, and trastuzumab; and then completed 5 years history is significant for stage II, estrogen receptor-positive, of tamoxifen. She and her partner now want to have a child. human epidermal growth factor 2—negative breast cancer diag- nosed 2 years ago. Her only medication is tamoxifen. Which of the following risks will be increased with On physical examination, vital signs are normal. The pregnancy? remainder of the examination is unremarkable. Complete blood count, comprehensive metabolic panel, ( ) Breast cancer recurrence > and thyroid-stimulating hormone level are all normal. ( B) Breast cancer-related mortality ( ) Congenital malformations in offspring Which of the following is the most appropriate treatment? Go © ( ) No increase in congenital malformations or breast (A) Discontinue tamoxifen cancer risk (B) Prescribe bupropion (C) Prescribe fluoxetine Item 17 (D) Prescribe venlafaxine A 55-year-old woman is evaluated in the office following a recent diagnosis of metastatic adenocarcinoma of the lung. She has excellent performance status. Medical history is Item 20 otherwise unremarkable, and she takes no medications. A 56-year-old woman is evaluated for findings suspicious There are no molecular alterations (epidermal growth for inflammatory breast cancer. factor receptor, ALK, ROS1). Programmed death ligand-1 On physical examination, vital signs are normal. The expression is negative. right breast is enlarged, and the skin is thickened and ery- thematous. There is a 5- x 4-cm mass in the lower outer Which of the following is the most appropriate treatment? breast. There is an enlarged right axillary node. Right breast mammogram reveals a mass in the lower (A) Combination chemotherapy outer breast with calcifications that span approximately (B) Combination chemotherapy plus pembrolizumab 5 cm in size. Right axillary ultrasound reveals an enlarged (C) Pembrolizumab monotherapy axillary lymph node. Core biopsy of the breast reveals (D) Single-agent chemotherapy estrogen receptor-negative, progesterone receptor- negative, and human epidermal growth factor 2—negative invasive ductal carcinoma. CT of the chest, abdomen, and Item 18 pelvis and bone scan show no evidence of distant meta- static disease. A 56-year-old man is evaluated for an enlarging, painful inguinal lymph node he first noticed 1 month ago. He has a history of follicular lymphoma of 8 years’ duration. The Which of the following is the most appropriate sequence patient was treated in the past with two courses of ritux- of therapies for this patient?

(D) Radiation therapy to the left inguinal nodes Item 16 A 37-year-old woman is evaluated 6 years after completing treatment for breast cancer. She has a history of stage II estro- Item 19 gen receptor—positive/human epidermal growth factor recep- A 41-year-old woman is evaluated for a 3-month history of tor 2-positive breast cancer. She underwent lumpectomy; depressed mood nearly every day, low energy, loss of interest irradiation; chemotherapy with doxorubicin, cyclophospha- in nearly all activities, fatigue, and poor concentration. Medical mide, paclitaxel, and trastuzumab; and then completed 5 years history is significant for stage II, estrogen receptor-positive, of tamoxifen. She and her partner now want to have a child. human epidermal growth factor 2—negative breast cancer diag- nosed 2 years ago. Her only medication is tamoxifen. Which of the following risks will be increased with On physical examination, vital signs are normal. The pregnancy? remainder of the examination is unremarkable. Complete blood count, comprehensive metabolic panel, ( ) Breast cancer recurrence > and thyroid-stimulating hormone level are all normal. ( B) Breast cancer-related mortality ( ) Congenital malformations in offspring Which of the following is the most appropriate treatment? Go © ( ) No increase in congenital malformations or breast (A) Discontinue tamoxifen cancer risk (B) Prescribe bupropion (C) Prescribe fluoxetine Item 17 (D) Prescribe venlafaxine A 55-year-old woman is evaluated in the office following a recent diagnosis of metastatic adenocarcinoma of the lung. She has excellent performance status. Medical history is Item 20 otherwise unremarkable, and she takes no medications. A 56-year-old woman is evaluated for findings suspicious There are no molecular alterations (epidermal growth for inflammatory breast cancer. factor receptor, ALK, ROS1). Programmed death ligand-1 On physical examination, vital signs are normal. The expression is negative. right breast is enlarged, and the skin is thickened and ery- thematous. There is a 5- x 4-cm mass in the lower outer Which of the following is the most appropriate treatment? breast. There is an enlarged right axillary node. Right breast mammogram reveals a mass in the lower (A) Combination chemotherapy outer breast with calcifications that span approximately (B) Combination chemotherapy plus pembrolizumab 5 cm in size. Right axillary ultrasound reveals an enlarged (C) Pembrolizumab monotherapy axillary lymph node. Core biopsy of the breast reveals (D) Single-agent chemotherapy estrogen receptor-negative, progesterone receptor- negative, and human epidermal growth factor 2—negative invasive ductal carcinoma. CT of the chest, abdomen, and Item 18 pelvis and bone scan show no evidence of distant meta- static disease. A 56-year-old man is evaluated for an enlarging, painful inguinal lymph node he first noticed 1 month ago. He has a history of follicular lymphoma of 8 years’ duration. The Which of the following is the most appropriate sequence patient was treated in the past with two courses of ritux- of therapies for this patient? imab 8 and 3 years ago with durable partial responses. For (A) Mastectomy, chemotherapy, irradiation the past 3 years, he had stable diffuse adenopathy managed (B) Preoperative chemotherapy, lumpectomy, irradiation with observation. He has no other symptoms. On physical examination, vital signs are normal. The (C) Preoperative chemotherapy, mastectomy, irradiation patient has diffuse adenopathy in the neck, axillae, and (D) Irradiation, mastectomy, chemotherapy right inguinal area and a new left inguinal conglomerate nodal mass measuring 5 x7 cm. Complete blood count and metabolic profile are Item 21 normal. A 45-year-old woman is evaluated for headaches and nau- PET/CT scan shows diffuse uptake in axillary, mediasti- sea that started 2 weeks ago. Her headaches are worse in the nal, hilar, and mesenteric nodes with elevated standardized morning and have been associated with vomiting.

imab 8 and 3 years ago with durable partial responses. For (A) Mastectomy, chemotherapy, irradiation the past 3 years, he had stable diffuse adenopathy managed (B) Preoperative chemotherapy, lumpectomy, irradiation with observation. He has no other symptoms. On physical examination, vital signs are normal. The (C) Preoperative chemotherapy, mastectomy, irradiation patient has diffuse adenopathy in the neck, axillae, and (D) Irradiation, mastectomy, chemotherapy right inguinal area and a new left inguinal conglomerate nodal mass measuring 5 x7 cm. Complete blood count and metabolic profile are Item 21 normal. A 45-year-old woman is evaluated for headaches and nau- PET/CT scan shows diffuse uptake in axillary, mediasti- sea that started 2 weeks ago. Her headaches are worse in the nal, hilar, and mesenteric nodes with elevated standardized morning and have been associated with vomiting. 56

Self-Assessment Test eal Medical history is significant for metastatic breast ultrasound biopsy showed multiple foci of prostate cancer od 4 cancer diagnosed 4 years ago. She is currently receiving in both lobes with the highest Gleason score of 8. det = treatment with capecitabine and trastuzumab. Additional On physical examination, vital signs and the remainder CY) medications are ondansetron and prochlorperazine. of the examination are normal. = 2) w On physical examination, vital signs are normal. Fun- CT and bone scan are negative for metastatic dis- a n duscopic examination findings are shown. ease. wn The patient has been started on treatment with andro- 3 = gen deprivation therapy plus radiation therapy. wy rn Which of the following is the most appropriate screening test to perform next? (A) Dementia screening (B) Doppler ultrasonography of the lower extremities (C) Dual-energy x-ray absorptiometry scan (D) Exercise stress test

(A) Dementia screening (B) Doppler ultrasonography of the lower extremities (C) Dual-energy x-ray absorptiometry scan (D) Exercise stress test Item 24 A 45-year-old man is evaluated following a recent diag- nosis of a gastrointestinal neuroendocrine tumor. The tumor was discovered after an abdominal CT scan for acute alcohol-related pancreatitis. The CT scan revealed more than 12 hypodense lesions in the liver ranging in size from 0.5 cm to 2.5 cm (replacing approximately 5% to 10% of the liver volume) and a 2-cm mesenteric mass. Following MRI of the brain reveals a 4-cm rim-enhancing lesion recovery from the pancreatitis, a core needle biopsy of in the left frontal lobe with surrounding vasogenic edema. one of the liver lesions was obtained and revealed a well- There is no midline shift or evidence of herniation. differentiated, low-grade neuroendocrine tumor. The patient reports feeling well since discharge from the hos- Which of the following is the most appropriate initial pital. He is enrolled in a 12-step facilitation program for treatment? alcohol use disorder. On physical examination, vital signs are normal. The (A) Dexamethasone remainder of the examination is normal. (B) Stereotactic radiation therapy (C) Surgical resection Which of the following is the most appropriate next step in (D) Whole brain radiation therapy management?

Which of the following is the most appropriate initial pital. He is enrolled in a 12-step facilitation program for treatment? alcohol use disorder. On physical examination, vital signs are normal. The (A) Dexamethasone remainder of the examination is normal. (B) Stereotactic radiation therapy (C) Surgical resection Which of the following is the most appropriate next step in (D) Whole brain radiation therapy management? (A) Expectant observation Item 22 (B) Hepatic artery embolization A 49-year-old woman is evaluated for pain and bright red (C) Peptide-receptor radiotherapy with radiolabeled blood with bowel movements for the past 6 weeks. somatostatin analogue Physical examination is notable only for a hard mass (D) Resection of the mesenteric mass palpable on rectal examination in the anal canal. Biopsy reveals squamous cell carcinoma. Pelvic MRI confirms a 4-cm anorectal mass. No Item 25 enlarged lymph nodes are noted. Contrast-enhanced CT A 63-year-old woman is evaluated in the hospital fol- scan of the chest and abdomen is normal. lowing successful treatment of severe hypercalcemia with intravenous fluids and zoledronic acid. She was Which of the following is the most appropriate treatment? subsequently diagnosed with widely metastatic, poorly

Physical examination is notable only for a hard mass (D) Resection of the mesenteric mass palpable on rectal examination in the anal canal. Biopsy reveals squamous cell carcinoma. Pelvic MRI confirms a 4-cm anorectal mass. No Item 25 enlarged lymph nodes are noted. Contrast-enhanced CT A 63-year-old woman is evaluated in the hospital fol- scan of the chest and abdomen is normal. lowing successful treatment of severe hypercalcemia with intravenous fluids and zoledronic acid. She was Which of the following is the most appropriate treatment? subsequently diagnosed with widely metastatic, poorly (A) Immunotherapy with programmed death receptor 1 differentiated adenocarcinoma of the lung. No tumor molecular alterations were noted. She has experienced inhibitor a 30-pound weight loss over the past 7 months. She has (B) Irradiation been unable to independently perform activities of daily (C) Irradiation with concurrent chemotherapy living for the past 4 months. She reports no significant (D) Surgical resection difficulty with pain. On physical examination, vital signs are normal. BMI is 19. She is cachectic and frail-appearing. Pulmonary exam- Item 23 ination reveals decreased breath sounds in the right lung A 65-year-old man is evaluated after being diagnosed with base. The patient is unable to transfer out of bed or walk high-risk prostate cancer. He is asymptomatic. Transrectal without assistance. 57

ee. rn ue, = Which of the following is the most appropriate surgery. Medical history is significant for a malignant mel- b= management? anoma that was resected from the right chest wall 4 years wn wa CONT. @ ago. A right axillary sentinel lymph node was negative at wn (A) Chemotherapy plus bevacizumab that time. Medical history is otherwise unremarkable, and = @ (B) Combination chemotherapy she takes no medications. = (C) Radiation therapy On physical examination, vital signs are normal. There -

ee. rn ue, = Which of the following is the most appropriate surgery. Medical history is significant for a malignant mel- b= management? anoma that was resected from the right chest wall 4 years wn wa CONT. @ ago. A right axillary sentinel lymph node was negative at wn (A) Chemotherapy plus bevacizumab that time. Medical history is otherwise unremarkable, and = @ (B) Combination chemotherapy she takes no medications. = (C) Radiation therapy On physical examination, vital signs are normal. There - = (D) Supportive care/hospice is a healed incision site from prior right chest wall mela- @o wn noma resection. There is no evidence of local or in-transit - recurrence and no axillary or other adenopathy. Item 26 PET/CT scan shows uptake in the right lung nodule but no other evidence of disease. CT-guided biopsy of the A 55-year-old woman is admitted to the hospital for che- right lung lesion shows BRAF V600E-mutated malignant motherapy following a diagnosis of Burkitt lymphoma. She melanoma. is considered to be at high risk for tumor lysis syndrome. On physical examination, blood pressure is 110/60 mm Hg and pulse rate is 110/min; the remainder of her vital Which of the following is the most appropriate initial signs are normal. The patient has large, palpable, bilateral treatment for this patient? cervical, supraclavicular, and axillary lymphadenopathy. (A) BRAF inhibitor Cardiopulmonary examination is normal. (B) BRAF inhibitor and a MEK inhibitor CT imaging of the chest, abdomen, and pelvis at the time of diagnosis revealed bulky mediastinal and periaortic (C) Immunotherapy lymphadenopathy. (D) Surgical resection Intravenous isotonic saline is administered at 200 mL/ hour. Item 29 Which of the following is the most appropriate additional A 32-year-old woman is evaluated after being diagnosed preventive therapy? with estrogen receptor-—positive breast cancer. The planned treatment strategy includes surgery, chemotherapy with (A) Acetazolamide docetaxel and cyclophosphamide, and 5 years of endocrine (B) Allopurinol therapy. She is interested in having children in the future. (C) Furosemide Medical history is otherwise unremarkable. (D) Rasburicase Which of the following is most likely to result in a subsequent pregnancy? Item 27 (A) Attempt conception during endocrine therapy A 59-year-old man is evaluated for a 2-month history of (B) Attempt conception after endocrine therapy worsening dry cough. He has no other symptoms. Medical history is otherwise unremarkable, and he takes no medi- (C) Depot leuprolide cations. (D) Embryo/oocyte cryopreservation On physical examination, vital signs are normal, and all other physical examination findings are unremarkable. CT scan of the chest reveals a 2.1-cm right middle lobe Item 30 mass and adjacent hilar adenopathy. PET/CT scan with flu- A 51-year-old man is evaluated following biopsy of the pros- orodeoxyglucose uptake in the known mass and hilar nodes tate gland. His father died of prostate cancer at the age of is otherwise negative. 60 years, and his mother was diagnosed with breast cancer Pathology at surgery reveals a 2.5-cm squamous cell at the age of 45 years. carcinoma with negative margins, two positive hilar nodes, Biopsy of the prostate revealed adenocarcinoma with and no positive mediastinal nodes. bilateral gland involvement; his Gleason score was 9. Bone Brain MRI scan is negative for metastatic disease. scan confirmed multiple osseous metastatic lesions.

= (D) Supportive care/hospice is a healed incision site from prior right chest wall mela- @o wn noma resection. There is no evidence of local or in-transit - recurrence and no axillary or other adenopathy. Item 26 PET/CT scan shows uptake in the right lung nodule but no other evidence of disease. CT-guided biopsy of the A 55-year-old woman is admitted to the hospital for che- right lung lesion shows BRAF V600E-mutated malignant motherapy following a diagnosis of Burkitt lymphoma. She melanoma. is considered to be at high risk for tumor lysis syndrome. On physical examination, blood pressure is 110/60 mm Hg and pulse rate is 110/min; the remainder of her vital Which of the following is the most appropriate initial signs are normal. The patient has large, palpable, bilateral treatment for this patient? cervical, supraclavicular, and axillary lymphadenopathy. (A) BRAF inhibitor Cardiopulmonary examination is normal. (B) BRAF inhibitor and a MEK inhibitor CT imaging of the chest, abdomen, and pelvis at the time of diagnosis revealed bulky mediastinal and periaortic (C) Immunotherapy lymphadenopathy. (D) Surgical resection Intravenous isotonic saline is administered at 200 mL/ hour. Item 29 Which of the following is the most appropriate additional A 32-year-old woman is evaluated after being diagnosed preventive therapy? with estrogen receptor-—positive breast cancer. The planned treatment strategy includes surgery, chemotherapy with (A) Acetazolamide docetaxel and cyclophosphamide, and 5 years of endocrine (B) Allopurinol therapy. She is interested in having children in the future. (C) Furosemide Medical history is otherwise unremarkable. (D) Rasburicase Which of the following is most likely to result in a subsequent pregnancy? Item 27 (A) Attempt conception during endocrine therapy A 59-year-old man is evaluated for a 2-month history of (B) Attempt conception after endocrine therapy worsening dry cough. He has no other symptoms. Medical history is otherwise unremarkable, and he takes no medi- (C) Depot leuprolide cations. (D) Embryo/oocyte cryopreservation On physical examination, vital signs are normal, and all other physical examination findings are unremarkable. CT scan of the chest reveals a 2.1-cm right middle lobe Item 30 mass and adjacent hilar adenopathy. PET/CT scan with flu- A 51-year-old man is evaluated following biopsy of the pros- orodeoxyglucose uptake in the known mass and hilar nodes tate gland. His father died of prostate cancer at the age of is otherwise negative. 60 years, and his mother was diagnosed with breast cancer Pathology at surgery reveals a 2.5-cm squamous cell at the age of 45 years. carcinoma with negative margins, two positive hilar nodes, Biopsy of the prostate revealed adenocarcinoma with and no positive mediastinal nodes. bilateral gland involvement; his Gleason score was 9. Bone Brain MRI scan is negative for metastatic disease. scan confirmed multiple osseous metastatic lesions. Which of the following is the most appropriate treatment? Which of the following is the most appropriate management?

= (D) Supportive care/hospice is a healed incision site from prior right chest wall mela- @o wn noma resection. There is no evidence of local or in-transit - recurrence and no axillary or other adenopathy. Item 26 PET/CT scan shows uptake in the right lung nodule but no other evidence of disease. CT-guided biopsy of the A 55-year-old woman is admitted to the hospital for che- right lung lesion shows BRAF V600E-mutated malignant motherapy following a diagnosis of Burkitt lymphoma. She melanoma. is considered to be at high risk for tumor lysis syndrome. On physical examination, blood pressure is 110/60 mm Hg and pulse rate is 110/min; the remainder of her vital Which of the following is the most appropriate initial signs are normal. The patient has large, palpable, bilateral treatment for this patient? cervical, supraclavicular, and axillary lymphadenopathy. (A) BRAF inhibitor Cardiopulmonary examination is normal. (B) BRAF inhibitor and a MEK inhibitor CT imaging of the chest, abdomen, and pelvis at the time of diagnosis revealed bulky mediastinal and periaortic (C) Immunotherapy lymphadenopathy. (D) Surgical resection Intravenous isotonic saline is administered at 200 mL/ hour. Item 29 Which of the following is the most appropriate additional A 32-year-old woman is evaluated after being diagnosed preventive therapy? with estrogen receptor-—positive breast cancer. The planned treatment strategy includes surgery, chemotherapy with (A) Acetazolamide docetaxel and cyclophosphamide, and 5 years of endocrine (B) Allopurinol therapy. She is interested in having children in the future. (C) Furosemide Medical history is otherwise unremarkable. (D) Rasburicase Which of the following is most likely to result in a subsequent pregnancy? Item 27 (A) Attempt conception during endocrine therapy A 59-year-old man is evaluated for a 2-month history of (B) Attempt conception after endocrine therapy worsening dry cough. He has no other symptoms. Medical history is otherwise unremarkable, and he takes no medi- (C) Depot leuprolide cations. (D) Embryo/oocyte cryopreservation On physical examination, vital signs are normal, and all other physical examination findings are unremarkable. CT scan of the chest reveals a 2.1-cm right middle lobe Item 30 mass and adjacent hilar adenopathy. PET/CT scan with flu- A 51-year-old man is evaluated following biopsy of the pros- orodeoxyglucose uptake in the known mass and hilar nodes tate gland. His father died of prostate cancer at the age of is otherwise negative. 60 years, and his mother was diagnosed with breast cancer Pathology at surgery reveals a 2.5-cm squamous cell at the age of 45 years. carcinoma with negative margins, two positive hilar nodes, Biopsy of the prostate revealed adenocarcinoma with and no positive mediastinal nodes. bilateral gland involvement; his Gleason score was 9. Bone Brain MRI scan is negative for metastatic disease. scan confirmed multiple osseous metastatic lesions. Which of the following is the most appropriate treatment? Which of the following is the most appropriate management? (A) Cisplatin-based chemotherapy (A) Cystoscopy (B) Combined cisplatin-based chemotherapy and irradia- (B) PET/CT tion (C) Prostate-specific antigen density measurement (C) Erlotinib (D) Referral to a genetic counselor (D) Prophylactic cranial irradiation

(A) Cisplatin-based chemotherapy (A) Cystoscopy (B) Combined cisplatin-based chemotherapy and irradia- (B) PET/CT tion (C) Prostate-specific antigen density measurement (C) Erlotinib (D) Referral to a genetic counselor (D) Prophylactic cranial irradiation ltem 31 Item 28 A 37-year-old woman is evaluated during a routine A 65-year-old woman is evaluated for a lung nodule found examination. Medical history is significant for Hodgkin on a preoperative chest radiograph for upcoming elective lymphoma, diagnosed at age 29 years and treated with 58

en DES SSR ETE Inet teed combination chemotherapy and mantle irradiation. There (C) Begin ciprofloxacin and amoxicillin/clavulanic acid; cH _— have been no recurrences of the Hodgkin lymphoma. Two — discharge the patient home i= years ago, she developed hypothyroidism. Her only medi- ao (D) Discharge the patient home with close follow-up cation is levothyroxine. = 2) wn On physical examination, vital signs are normal. There a wn are no breast masses or nodules and no axillary adenopathy. Item 34 2)

have been no recurrences of the Hodgkin lymphoma. Two — discharge the patient home i= years ago, she developed hypothyroidism. Her only medi- ao (D) Discharge the patient home with close follow-up cation is levothyroxine. = 2) wn On physical examination, vital signs are normal. There a wn are no breast masses or nodules and no axillary adenopathy. Item 34 2) The remainder of the examination is normal. = A 64-year-old woman is evaluated in the office following a ms a diagnosis of metastatic breast cancer. Six years ago, she was (7) Which of the following screening tests should be done now? diagnosed with breast cancer and treated with lumpectomy,

The remainder of the examination is normal. = A 64-year-old woman is evaluated in the office following a ms a diagnosis of metastatic breast cancer. Six years ago, she was (7) Which of the following screening tests should be done now? diagnosed with breast cancer and treated with lumpectomy, (A) Mammography irradiation, and a complete course of adjuvant hormonal therapy. Two weeks ago, a bone lytic lesion was found on (B) Mammography and MRI of the breast a lumbar spine radiograph taken for low back pain after (C) MRI of the breast a fall while playing tennis. Subsequent CT scans revealed (D) Ultrasonography of the breast diffuse involvement of her axial skeleton with no associated fractures and no epidural extension. The patient is currently Item 32 asymptomatic. Medical history is unremarkable, and she takes no medications. A 74-year-old woman is evaluated for cough and dyspnea On physical examination, vital signs are within normal on exertion, which has progressed over the past 6 months. limits, and examination findings are unremarkable. Medical history is otherwise unremarkable, and she takes Systemic therapy for metastatic breast cancer is no medications. planned. On physical examination, vital signs are normal. There are scattered crackles throughout the left chest. There is no adenopathy. Which of the following is the most appropriate additional CT scan of the chest, abdomen, and pelvis shows only treatment? patchy, nodular infiltrates in the left upper and left lower (A) Calcium and vitamin D lobes of the lung. (B) Spine irradiation Transbronchial lung biopsy shows non-Hodgkin, mucosa-associated lymphoid tissue lymphoma. (C) Teriparatide (D) Zoledronic acid Which of the following is the most appropriate management? Item 35 (A) Combination chemoimmunotherapy with rituximab, A 46-year-old woman is evaluated for swelling and dis- cyclophosphamide, doxorubicin, vincristine, and comfort around her left breast prosthesis. She underwent prednisone bilateral prophylactic mastectomies with subsequent tex- (B) Left pneumonectomy tured implant reconstruction 8 years ago by choice related (C) Helicobacter pylori eradication treatment to family history of ductal carcinoma in situ. Medical history (D) Rituximab is otherwise unremarkable. On physical examination, vital signs are normal. There is moderate swelling and tenderness around the left breast pros- Item 33 thesis. There are no nodules, erythema, or other skin changes. A 37-year-old woman is evaluated in the emergency depart- Complete blood count is normal. ment for fever 1 week after her second cycle of chemotherapy Ultrasound of the left chest wall shows a moderate- for breast cancer. She has no focal symptoms, is otherwise sized fluid collection around the prosthesis. There is no evi- healthy, and takes no medications. The patient lives with her dence of prosthetic rupture. Aspiration of the fluid shows partner 20 minutes from the hospital. serous, nonpurulent fluid. On physical examination, temperature is 38.3 °C (101 °F); other vital signs are normal. She appears well. There is a Which of the following is the most likely diagnosis? healed right mastectomy incision, and the left chest port is in place without erythema or tenderness. ( A) Anaplastic T-cell lymphoma Laboratory studies show a leukocyte count of 1,600/uL ( B) Autoimmune serositis (1.6 x 10 °/L) with an absolute neutrophil count of 600/pL ( C) Breast cancer (0.6 x 109/L), hemoglobin level of 11.1 g/dL (111 g/L), and platelet count 167,000/uL (167 x 10 9/L). Urinalysis and basic ( D) Infection of the breast implant metabolic panel are normal. Blood cultures are obtained. Chest radiograph is normal. Item 36

(A) Mammography irradiation, and a complete course of adjuvant hormonal therapy. Two weeks ago, a bone lytic lesion was found on (B) Mammography and MRI of the breast a lumbar spine radiograph taken for low back pain after (C) MRI of the breast a fall while playing tennis. Subsequent CT scans revealed (D) Ultrasonography of the breast diffuse involvement of her axial skeleton with no associated fractures and no epidural extension. The patient is currently Item 32 asymptomatic. Medical history is unremarkable, and she takes no medications. A 74-year-old woman is evaluated for cough and dyspnea On physical examination, vital signs are within normal on exertion, which has progressed over the past 6 months. limits, and examination findings are unremarkable. Medical history is otherwise unremarkable, and she takes Systemic therapy for metastatic breast cancer is no medications. planned. On physical examination, vital signs are normal. There are scattered crackles throughout the left chest. There is no adenopathy. Which of the following is the most appropriate additional CT scan of the chest, abdomen, and pelvis shows only treatment? patchy, nodular infiltrates in the left upper and left lower (A) Calcium and vitamin D lobes of the lung. (B) Spine irradiation Transbronchial lung biopsy shows non-Hodgkin, mucosa-associated lymphoid tissue lymphoma. (C) Teriparatide (D) Zoledronic acid Which of the following is the most appropriate management? Item 35 (A) Combination chemoimmunotherapy with rituximab, A 46-year-old woman is evaluated for swelling and dis- cyclophosphamide, doxorubicin, vincristine, and comfort around her left breast prosthesis. She underwent prednisone bilateral prophylactic mastectomies with subsequent tex- (B) Left pneumonectomy tured implant reconstruction 8 years ago by choice related (C) Helicobacter pylori eradication treatment to family history of ductal carcinoma in situ. Medical history (D) Rituximab is otherwise unremarkable. On physical examination, vital signs are normal. There is moderate swelling and tenderness around the left breast pros- Item 33 thesis. There are no nodules, erythema, or other skin changes. A 37-year-old woman is evaluated in the emergency depart- Complete blood count is normal. ment for fever 1 week after her second cycle of chemotherapy Ultrasound of the left chest wall shows a moderate- for breast cancer. She has no focal symptoms, is otherwise sized fluid collection around the prosthesis. There is no evi- healthy, and takes no medications. The patient lives with her dence of prosthetic rupture. Aspiration of the fluid shows partner 20 minutes from the hospital. serous, nonpurulent fluid. On physical examination, temperature is 38.3 °C (101 °F); other vital signs are normal. She appears well. There is a Which of the following is the most likely diagnosis? healed right mastectomy incision, and the left chest port is in place without erythema or tenderness. ( A) Anaplastic T-cell lymphoma Laboratory studies show a leukocyte count of 1,600/uL ( B) Autoimmune serositis (1.6 x 10 °/L) with an absolute neutrophil count of 600/pL ( C) Breast cancer (0.6 x 109/L), hemoglobin level of 11.1 g/dL (111 g/L), and platelet count 167,000/uL (167 x 10 9/L). Urinalysis and basic ( D) Infection of the breast implant metabolic panel are normal. Blood cultures are obtained. Chest radiograph is normal. Item 36 Which of the following is the most appropriate treatment A 27-year-old woman is evaluated following a recently con- for this patient? firmed diagnosis of early-stage nodular sclerosing Hodgkin lymphoma. She has had no fevers, night sweats, or weight (A) Begin cefepime; admit the patient loss. Medical history is unremarkable, and she takes no (B) Begin cefepime and gentamicin; admit the patient medications.

Which of the following is the most appropriate treatment A 27-year-old woman is evaluated following a recently con- for this patient? firmed diagnosis of early-stage nodular sclerosing Hodgkin lymphoma. She has had no fevers, night sweats, or weight (A) Begin cefepime; admit the patient loss. Medical history is unremarkable, and she takes no (B) Begin cefepime and gentamicin; admit the patient medications. 59

Self-Assessment Test rn pr = On physical examination, vital signs are normal. There (C) Repeat prostate biopsy > is a healing surgical scar over the mid left neck. A 3- x 2-cm wn (D) Repeat PSA measurement in 6 months un @o left supraclavicular lymph node is palpable. There is no wn a other adenopathy and no hepatosplenomegaly. = Complete blood count is normal. Erythrocyte sedimen- Item 39 @o = tation rate is 22 mm/h. - A 71-year-old man is evaluated during a follow-up visit. CT and PET scans detect left cervical and supraclavic- He underwent radical prostatectomy for prostate cancer a ular adenopathy as well as an anterior mediastinal mass w ote 10 years ago. Androgen deprivation therapy was initiated measuring 5 x 4cm. No infradiaphragmatic disease is noted. 6 years ago for rising prostate-specific antigen (PSA) lev- els. His PSA fell rapidly and became undetectable until Which of the following is the most appropriate 6 months ago, when it rose from 0.7 ng/mL (0.7 ug/L) to management? its present level of 5 ng/mL (5 pg/L). Testosterone remains (A) Checkpoint inhibitor immunotherapy suppressed. Medical history is otherwise unremarkable, and his only medication is leuprolide acetate. (B) Combination chemotherapy followed by autologous On physical examination, vital signs are normal, and all hematopoietic stem cell transplantation examination findings are unremarkable. (C) Combination chemotherapy followed by radiation CT and bone scan show no evidence of metastatic therapy disease. (D) Radiation therapy alone Which of the following is the most appropriate treatment at this time? Item 37 (A) Androgen receptor blocker A 38-year-old man is evaluated for abdominal pain of sev- (B) Bone-seeking isotope eral weeks’ duration. On physical examination, vital signs are normal. The (C) Chemotherapy abdomen is diffusely distended and firm with a 10-cm pal- (D) CYP17 inhibitor pable lower abdominal mass. Laboratory studies reveal a creatinine concentration of 1.8 mg/dL (159.1 umol/L), a potassium concentration of Item 40 4.9 mEq/L (4.9 mmol/L), and a uric acid concentration of A 50-year-old woman is evaluated for heaviness and swell- 8.2 mg/dL (0.48 mmol/L). ing of her left breast of 3 weeks’ duration. One week ago, Results of the chest radiograph are normal. CT scan of the she noticed that her outer breast had a pink appearance. abdomen shows diffuse, bulky mesenteric and retroperitoneal Medical history is otherwise unremarkable, and she takes adenopathy. Biopsy of the mass reveals Burkitt lymphoma. no medications. Multiagent chemotherapy containing doxorubicin is On physical examination, vital signs are normal. Breast planned. findings are shown.

rn pr = On physical examination, vital signs are normal. There (C) Repeat prostate biopsy > is a healing surgical scar over the mid left neck. A 3- x 2-cm wn (D) Repeat PSA measurement in 6 months un @o left supraclavicular lymph node is palpable. There is no wn a other adenopathy and no hepatosplenomegaly. = Complete blood count is normal. Erythrocyte sedimen- Item 39 @o = tation rate is 22 mm/h. - A 71-year-old man is evaluated during a follow-up visit. CT and PET scans detect left cervical and supraclavic- He underwent radical prostatectomy for prostate cancer a ular adenopathy as well as an anterior mediastinal mass w ote 10 years ago. Androgen deprivation therapy was initiated measuring 5 x 4cm. No infradiaphragmatic disease is noted. 6 years ago for rising prostate-specific antigen (PSA) lev- els. His PSA fell rapidly and became undetectable until Which of the following is the most appropriate 6 months ago, when it rose from 0.7 ng/mL (0.7 ug/L) to management? its present level of 5 ng/mL (5 pg/L). Testosterone remains (A) Checkpoint inhibitor immunotherapy suppressed. Medical history is otherwise unremarkable, and his only medication is leuprolide acetate. (B) Combination chemotherapy followed by autologous On physical examination, vital signs are normal, and all hematopoietic stem cell transplantation examination findings are unremarkable. (C) Combination chemotherapy followed by radiation CT and bone scan show no evidence of metastatic therapy disease. (D) Radiation therapy alone Which of the following is the most appropriate treatment at this time? Item 37 (A) Androgen receptor blocker A 38-year-old man is evaluated for abdominal pain of sev- (B) Bone-seeking isotope eral weeks’ duration. On physical examination, vital signs are normal. The (C) Chemotherapy abdomen is diffusely distended and firm with a 10-cm pal- (D) CYP17 inhibitor pable lower abdominal mass. Laboratory studies reveal a creatinine concentration of 1.8 mg/dL (159.1 umol/L), a potassium concentration of Item 40 4.9 mEq/L (4.9 mmol/L), and a uric acid concentration of A 50-year-old woman is evaluated for heaviness and swell- 8.2 mg/dL (0.48 mmol/L). ing of her left breast of 3 weeks’ duration. One week ago, Results of the chest radiograph are normal. CT scan of the she noticed that her outer breast had a pink appearance. abdomen shows diffuse, bulky mesenteric and retroperitoneal Medical history is otherwise unremarkable, and she takes adenopathy. Biopsy of the mass reveals Burkitt lymphoma. no medications. Multiagent chemotherapy containing doxorubicin is On physical examination, vital signs are normal. Breast planned. findings are shown. Which of the following is the most likely immediate treatment-associated complication?

rn pr = On physical examination, vital signs are normal. There (C) Repeat prostate biopsy > is a healing surgical scar over the mid left neck. A 3- x 2-cm wn (D) Repeat PSA measurement in 6 months un @o left supraclavicular lymph node is palpable. There is no wn a other adenopathy and no hepatosplenomegaly. = Complete blood count is normal. Erythrocyte sedimen- Item 39 @o = tation rate is 22 mm/h. - A 71-year-old man is evaluated during a follow-up visit. CT and PET scans detect left cervical and supraclavic- He underwent radical prostatectomy for prostate cancer a ular adenopathy as well as an anterior mediastinal mass w ote 10 years ago. Androgen deprivation therapy was initiated measuring 5 x 4cm. No infradiaphragmatic disease is noted. 6 years ago for rising prostate-specific antigen (PSA) lev- els. His PSA fell rapidly and became undetectable until Which of the following is the most appropriate 6 months ago, when it rose from 0.7 ng/mL (0.7 ug/L) to management? its present level of 5 ng/mL (5 pg/L). Testosterone remains (A) Checkpoint inhibitor immunotherapy suppressed. Medical history is otherwise unremarkable, and his only medication is leuprolide acetate. (B) Combination chemotherapy followed by autologous On physical examination, vital signs are normal, and all hematopoietic stem cell transplantation examination findings are unremarkable. (C) Combination chemotherapy followed by radiation CT and bone scan show no evidence of metastatic therapy disease. (D) Radiation therapy alone Which of the following is the most appropriate treatment at this time? Item 37 (A) Androgen receptor blocker A 38-year-old man is evaluated for abdominal pain of sev- (B) Bone-seeking isotope eral weeks’ duration. On physical examination, vital signs are normal. The (C) Chemotherapy abdomen is diffusely distended and firm with a 10-cm pal- (D) CYP17 inhibitor pable lower abdominal mass. Laboratory studies reveal a creatinine concentration of 1.8 mg/dL (159.1 umol/L), a potassium concentration of Item 40 4.9 mEq/L (4.9 mmol/L), and a uric acid concentration of A 50-year-old woman is evaluated for heaviness and swell- 8.2 mg/dL (0.48 mmol/L). ing of her left breast of 3 weeks’ duration. One week ago, Results of the chest radiograph are normal. CT scan of the she noticed that her outer breast had a pink appearance. abdomen shows diffuse, bulky mesenteric and retroperitoneal Medical history is otherwise unremarkable, and she takes adenopathy. Biopsy of the mass reveals Burkitt lymphoma. no medications. Multiagent chemotherapy containing doxorubicin is On physical examination, vital signs are normal. Breast planned. findings are shown. Which of the following is the most likely immediate treatment-associated complication? (A) Cardiotoxicity (B) Hypercalcemia (C) Tumor lysis syndrome (D) Superior vena cava syndrome

rn pr = On physical examination, vital signs are normal. There (C) Repeat prostate biopsy > is a healing surgical scar over the mid left neck. A 3- x 2-cm wn (D) Repeat PSA measurement in 6 months un @o left supraclavicular lymph node is palpable. There is no wn a other adenopathy and no hepatosplenomegaly. = Complete blood count is normal. Erythrocyte sedimen- Item 39 @o = tation rate is 22 mm/h. - A 71-year-old man is evaluated during a follow-up visit. CT and PET scans detect left cervical and supraclavic- He underwent radical prostatectomy for prostate cancer a ular adenopathy as well as an anterior mediastinal mass w ote 10 years ago. Androgen deprivation therapy was initiated measuring 5 x 4cm. No infradiaphragmatic disease is noted. 6 years ago for rising prostate-specific antigen (PSA) lev- els. His PSA fell rapidly and became undetectable until Which of the following is the most appropriate 6 months ago, when it rose from 0.7 ng/mL (0.7 ug/L) to management? its present level of 5 ng/mL (5 pg/L). Testosterone remains (A) Checkpoint inhibitor immunotherapy suppressed. Medical history is otherwise unremarkable, and his only medication is leuprolide acetate. (B) Combination chemotherapy followed by autologous On physical examination, vital signs are normal, and all hematopoietic stem cell transplantation examination findings are unremarkable. (C) Combination chemotherapy followed by radiation CT and bone scan show no evidence of metastatic therapy disease. (D) Radiation therapy alone Which of the following is the most appropriate treatment at this time? Item 37 (A) Androgen receptor blocker A 38-year-old man is evaluated for abdominal pain of sev- (B) Bone-seeking isotope eral weeks’ duration. On physical examination, vital signs are normal. The (C) Chemotherapy abdomen is diffusely distended and firm with a 10-cm pal- (D) CYP17 inhibitor pable lower abdominal mass. Laboratory studies reveal a creatinine concentration of 1.8 mg/dL (159.1 umol/L), a potassium concentration of Item 40 4.9 mEq/L (4.9 mmol/L), and a uric acid concentration of A 50-year-old woman is evaluated for heaviness and swell- 8.2 mg/dL (0.48 mmol/L). ing of her left breast of 3 weeks’ duration. One week ago, Results of the chest radiograph are normal. CT scan of the she noticed that her outer breast had a pink appearance. abdomen shows diffuse, bulky mesenteric and retroperitoneal Medical history is otherwise unremarkable, and she takes adenopathy. Biopsy of the mass reveals Burkitt lymphoma. no medications. Multiagent chemotherapy containing doxorubicin is On physical examination, vital signs are normal. Breast planned. findings are shown. Which of the following is the most likely immediate treatment-associated complication? (A) Cardiotoxicity (B) Hypercalcemia (C) Tumor lysis syndrome (D) Superior vena cava syndrome Item 38 A 70-year-old man undergoes routine follow-up evalua- tion of low-risk prostate cancer diagnosed 3 years ago. He reports no symptoms. He has been managed with active sur- veillance. His last biopsy was 18 months ago. His prostate- specific antigen (PSA) level was 4.5 ng/mL (4.5 ug/L) 1 year ago and is now 9.2 ng/mL (9.2 ug/L). He takes no medications. On physical examination, vital signs and all examina- Breast examination reveals no masses or tenderness. tion findings are unremarkable. Results of the complete blood count with differential are normal. Which of the following is the most appropriate management? Which of the following is the most likely diagnosis?

Item 38 A 70-year-old man undergoes routine follow-up evalua- tion of low-risk prostate cancer diagnosed 3 years ago. He reports no symptoms. He has been managed with active sur- veillance. His last biopsy was 18 months ago. His prostate- specific antigen (PSA) level was 4.5 ng/mL (4.5 ug/L) 1 year ago and is now 9.2 ng/mL (9.2 ug/L). He takes no medications. On physical examination, vital signs and all examina- Breast examination reveals no masses or tenderness. tion findings are unremarkable. Results of the complete blood count with differential are normal. Which of the following is the most appropriate management? Which of the following is the most likely diagnosis? (A) Bone scan (A) Breast abscess (B) Free PSA measurement (B) Ductal ectasia 60

Self-Assessment Test pos cH (C) Inflammatory breast cancer (C) Intravenous isotonic saline and furosemide i 7 (D) Mastitis (D) Zoledronic acid = ov = wn wn Item 41 Item 44 a wn wn A 69-year-old woman undergoes follow-up evaluation for A 33-year-old man is evaluated for a 12-week history of = stage III colon cancer, which was resected 2 years ago. She night sweats, fevers, and a 2.5-kg (5.6-Ib) weight loss with- eS a is asymptomatic and takes no medications. out other localizing symptoms. Medical history is otherwise nr

(D) Mastitis (D) Zoledronic acid = ov = wn wn Item 41 Item 44 a wn wn A 69-year-old woman undergoes follow-up evaluation for A 33-year-old man is evaluated for a 12-week history of = stage III colon cancer, which was resected 2 years ago. She night sweats, fevers, and a 2.5-kg (5.6-Ib) weight loss with- eS a is asymptomatic and takes no medications. out other localizing symptoms. Medical history is otherwise nr On physical examination, vital signs and examination unremarkable, and he takes no medications. findings are unremarkable. On thorough physical examination, temperature is Surveillance CT scan of the chest, abdomen, and pelvis 38.1 °C (100.6 °F); the remainder of vital signs are normal. reveals a new 3-cm lesion and a 2.5-cm lesion, both in the Bilateral supraclavicular lymphadenopathy is noted. The right lobe of the liver. No other abnormalities are noted. examination is otherwise unremarkable. Complete blood count, comprehensive metabolic Which of the following is the most appropriate treatment? profile, and serum o-fetoprotein and B-human chorionic gonadotropin levels are normal. (A) Hepatic artery embolization Testicular ultrasonography is normal. Contrast- (B) Needle biopsy of the largest lesion enhanced CT scan of the chest, abdomen, and pelvis shows (C) Resection of the two lesions bulky retroperitoneal, mediastinal, and supraclavicular adenopathy. (D) Systemic chemotherapy An excisional biopsy of a supraclavicular node shows poorly differentiated carcinoma.

On physical examination, vital signs and examination unremarkable, and he takes no medications. findings are unremarkable. On thorough physical examination, temperature is Surveillance CT scan of the chest, abdomen, and pelvis 38.1 °C (100.6 °F); the remainder of vital signs are normal. reveals a new 3-cm lesion and a 2.5-cm lesion, both in the Bilateral supraclavicular lymphadenopathy is noted. The right lobe of the liver. No other abnormalities are noted. examination is otherwise unremarkable. Complete blood count, comprehensive metabolic Which of the following is the most appropriate treatment? profile, and serum o-fetoprotein and B-human chorionic gonadotropin levels are normal. (A) Hepatic artery embolization Testicular ultrasonography is normal. Contrast- (B) Needle biopsy of the largest lesion enhanced CT scan of the chest, abdomen, and pelvis shows (C) Resection of the two lesions bulky retroperitoneal, mediastinal, and supraclavicular adenopathy. (D) Systemic chemotherapy An excisional biopsy of a supraclavicular node shows poorly differentiated carcinoma. Item 42 Which of the following is the most appropriate A 67-year-old woman is about to begin highly emetogenic management? chemotherapy with cyclophosphamide and doxorubicin for stage III breast cancer. (A) Chemotherapy with a cisplatin-based germ cell regimen On physical examination, vital signs are normal. There (B) Chemotherapy with a fluorouracil-based gastrointes- is a healed left lumpectomy incision and a sentinel node tinal cancer regimen sampling incision. The left chest port is in place. (C) Stereotactic radiation therapy to involved lymph nodes (D) Surgical debulking of nodal disease Which of the following is the most appropriate management of this patient’s potential for nausea and vomiting? Item 45 (A) Lorazepam A 58-year-old woman undergoes follow-up evaluation for (B) Medical marijuana recently diagnosed breast cancer following lumpectomy (C) Ondansetron, aprepitant, olanzapine, and dexameth- and sentinel lymph node biopsy. Pathology of the primary

Item 42 Which of the following is the most appropriate A 67-year-old woman is about to begin highly emetogenic management? chemotherapy with cyclophosphamide and doxorubicin for stage III breast cancer. (A) Chemotherapy with a cisplatin-based germ cell regimen On physical examination, vital signs are normal. There (B) Chemotherapy with a fluorouracil-based gastrointes- is a healed left lumpectomy incision and a sentinel node tinal cancer regimen sampling incision. The left chest port is in place. (C) Stereotactic radiation therapy to involved lymph nodes (D) Surgical debulking of nodal disease Which of the following is the most appropriate management of this patient’s potential for nausea and vomiting? Item 45 (A) Lorazepam A 58-year-old woman undergoes follow-up evaluation for (B) Medical marijuana recently diagnosed breast cancer following lumpectomy (C) Ondansetron, aprepitant, olanzapine, and dexameth- and sentinel lymph node biopsy. Pathology of the primary asone tumor revealed a 2.3-cm, grade II, estrogen receptor- positive, human epidermal growth factor 2-negative breast (D) Ondansetron or dexamethasone cancer. Two sentinel axillary lymph nodes were negative for cancer. Her medical history is otherwise unremarkable, and she takes no medications. Item 43 Local irradiation is planned. A 66-year-old man is evaluated for increased confusion and lethargy over the past 2 days, as well as nausea and vomiting. Which of the following is the most appropriate He has also had diffuse bone pain that began 6 weeks ago management of the patient’s systemic therapy? and has worsened over the past month. His medical history is otherwise unremarkable, and he takes no medications. (A) Chemotherapy alone On physical examination, temperature is 36.4 °C (97.6 °F), (B) Chemotherapy followed by endocrine therapy for 5 years blood pressure is 110/60 mm Hg, pulse rate is 110/min, (C) Endocrine therapy alone and respiration rate is 16/min. He is somnolent but can be (D) Multigene recurrence assay aroused. Mucous membranes are dry, and he has decreased skin turgor. Cardiopulmonary examination is normal. Results of laboratory studies show an albumin level of Item 46 3.8 g/dL (38 g/L), calcium level of 14.8 mg/dL (3.7 mmol/L), and creatinine level of 2.5 mg/dL (221 umol/L). A 42-year-old man is evaluated for a 3-month history of worsening fatigue, weight loss, back pain, cough, and

asone tumor revealed a 2.3-cm, grade II, estrogen receptor- positive, human epidermal growth factor 2-negative breast (D) Ondansetron or dexamethasone cancer. Two sentinel axillary lymph nodes were negative for cancer. Her medical history is otherwise unremarkable, and she takes no medications. Item 43 Local irradiation is planned. A 66-year-old man is evaluated for increased confusion and lethargy over the past 2 days, as well as nausea and vomiting. Which of the following is the most appropriate He has also had diffuse bone pain that began 6 weeks ago management of the patient’s systemic therapy? and has worsened over the past month. His medical history is otherwise unremarkable, and he takes no medications. (A) Chemotherapy alone On physical examination, temperature is 36.4 °C (97.6 °F), (B) Chemotherapy followed by endocrine therapy for 5 years blood pressure is 110/60 mm Hg, pulse rate is 110/min, (C) Endocrine therapy alone and respiration rate is 16/min. He is somnolent but can be (D) Multigene recurrence assay aroused. Mucous membranes are dry, and he has decreased skin turgor. Cardiopulmonary examination is normal. Results of laboratory studies show an albumin level of Item 46 3.8 g/dL (38 g/L), calcium level of 14.8 mg/dL (3.7 mmol/L), and creatinine level of 2.5 mg/dL (221 umol/L). A 42-year-old man is evaluated for a 3-month history of worsening fatigue, weight loss, back pain, cough, and Which of the following is the most appropriate initial hemoptysis. Medical history is otherwise unremarkable,

asone tumor revealed a 2.3-cm, grade II, estrogen receptor- positive, human epidermal growth factor 2-negative breast (D) Ondansetron or dexamethasone cancer. Two sentinel axillary lymph nodes were negative for cancer. Her medical history is otherwise unremarkable, and she takes no medications. Item 43 Local irradiation is planned. A 66-year-old man is evaluated for increased confusion and lethargy over the past 2 days, as well as nausea and vomiting. Which of the following is the most appropriate He has also had diffuse bone pain that began 6 weeks ago management of the patient’s systemic therapy? and has worsened over the past month. His medical history is otherwise unremarkable, and he takes no medications. (A) Chemotherapy alone On physical examination, temperature is 36.4 °C (97.6 °F), (B) Chemotherapy followed by endocrine therapy for 5 years blood pressure is 110/60 mm Hg, pulse rate is 110/min, (C) Endocrine therapy alone and respiration rate is 16/min. He is somnolent but can be (D) Multigene recurrence assay aroused. Mucous membranes are dry, and he has decreased skin turgor. Cardiopulmonary examination is normal. Results of laboratory studies show an albumin level of Item 46 3.8 g/dL (38 g/L), calcium level of 14.8 mg/dL (3.7 mmol/L), and creatinine level of 2.5 mg/dL (221 umol/L). A 42-year-old man is evaluated for a 3-month history of worsening fatigue, weight loss, back pain, cough, and Which of the following is the most appropriate initial hemoptysis. Medical history is otherwise unremarkable, management? and he takes no medications. On physical examination, vital signs are normal. Pul- (A) Denosumab monary examination reveals decreased breath sounds in (B) Intravenous isotonic saline and calcitonin the left lung base.

management? and he takes no medications. On physical examination, vital signs are normal. Pul- (A) Denosumab monary examination reveals decreased breath sounds in (B) Intravenous isotonic saline and calcitonin the left lung base. 61

Self-Assessment Test 7 rn 2: = Chest radiograph reveals a moderate-sized left pleu- On physical examination, vital signs are normal. Dif- > m) ral effusion. CT scan of the chest shows left-sided pleural fuse adenopathy with nodes 1.5 to 2 cm is present in cervi- 72) @o effusion and a large medial lung mass. Multiple osseous cal, axillary, and inguinal areas. The spleen is enlarged 2 cm 7) 72) metastatic lesions and bilateral adrenal metastases are also below the left costal margin. = identified. Brain MRI is negative for metastatic disease. Results of laboratory studies show a leukocyte count of @ = Thoracentesis is positive for adenocarcinoma. Molecu- 62,000/uL (62 x 10 °/L) with 90% lymphocytes, hemoglobin -

rn 2: = Chest radiograph reveals a moderate-sized left pleu- On physical examination, vital signs are normal. Dif- > m) ral effusion. CT scan of the chest shows left-sided pleural fuse adenopathy with nodes 1.5 to 2 cm is present in cervi- 72) @o effusion and a large medial lung mass. Multiple osseous cal, axillary, and inguinal areas. The spleen is enlarged 2 cm 7) 72) metastatic lesions and bilateral adrenal metastases are also below the left costal margin. = identified. Brain MRI is negative for metastatic disease. Results of laboratory studies show a leukocyte count of @ = Thoracentesis is positive for adenocarcinoma. Molecu- 62,000/uL (62 x 10 °/L) with 90% lymphocytes, hemoglobin - ol lar testing is positive only for ALK translocation. level of 12.8 g/dL (128 g/L), and platelet count 152,000/pL @o wn (152 x 10 °/L). Flow cytometry shows a predominance of oe Which of the following is the most appropriate treatment? CD5, CD19, and CD20 cells expressing only « light chains consistent with chronic lymphocytic leukemia. (A) Alectinib (B) Combined chemotherapy and pembrolizumab Which of the following is the most appropriate (C) Platinum-based chemotherapy management? (D) Stereotactic radiation therapy (A) Bone marrow biopsy (B) Begin ibrutinib Item 47 (C) Begin rituximab and bendamustine A 73-year-old woman seeks advice before beginning a new (D) Proceed with elective surgery chemotherapy regimen for metastatic adenocarcinoma of the colon. The new chemotherapy protocol has a modest Item 50 progression-free survival benefit over a placebo but with increased toxicity. She is currently feeling well, has minor A 34-year-old woman undergoes consultation after a recent

ol lar testing is positive only for ALK translocation. level of 12.8 g/dL (128 g/L), and platelet count 152,000/pL @o wn (152 x 10 °/L). Flow cytometry shows a predominance of oe Which of the following is the most appropriate treatment? CD5, CD19, and CD20 cells expressing only « light chains consistent with chronic lymphocytic leukemia. (A) Alectinib (B) Combined chemotherapy and pembrolizumab Which of the following is the most appropriate (C) Platinum-based chemotherapy management? (D) Stereotactic radiation therapy (A) Bone marrow biopsy (B) Begin ibrutinib Item 47 (C) Begin rituximab and bendamustine A 73-year-old woman seeks advice before beginning a new (D) Proceed with elective surgery chemotherapy regimen for metastatic adenocarcinoma of the colon. The new chemotherapy protocol has a modest Item 50 progression-free survival benefit over a placebo but with increased toxicity. She is currently feeling well, has minor A 34-year-old woman undergoes consultation after a recent tumor pain controlled with occasional use of ibuprofen, and diagnosis of stage IB cervical cancer. She is nulliparous, and

ol lar testing is positive only for ALK translocation. level of 12.8 g/dL (128 g/L), and platelet count 152,000/pL @o wn (152 x 10 °/L). Flow cytometry shows a predominance of oe Which of the following is the most appropriate treatment? CD5, CD19, and CD20 cells expressing only « light chains consistent with chronic lymphocytic leukemia. (A) Alectinib (B) Combined chemotherapy and pembrolizumab Which of the following is the most appropriate (C) Platinum-based chemotherapy management? (D) Stereotactic radiation therapy (A) Bone marrow biopsy (B) Begin ibrutinib Item 47 (C) Begin rituximab and bendamustine A 73-year-old woman seeks advice before beginning a new (D) Proceed with elective surgery chemotherapy regimen for metastatic adenocarcinoma of the colon. The new chemotherapy protocol has a modest Item 50 progression-free survival benefit over a placebo but with increased toxicity. She is currently feeling well, has minor A 34-year-old woman undergoes consultation after a recent tumor pain controlled with occasional use of ibuprofen, and diagnosis of stage IB cervical cancer. She is nulliparous, and continues to work full time. she and her partner are hoping to have children. Medical history is unremarkable, and she takes no medications. Colposcopy-directed biopsy of the cervix revealed Which of the following results can the patient reasonably squamous cell carcinoma with invasion to 6 mm in depth. expect with the new chemotherapy regimen? There is no radiographic evidence of pelvic or abdominal (A) Greater probability of cure adenopathy and no evidence of distant metastatic disease. (B) Improved quality of life (C) Longer life Which of the following is the most appropriate treatment?

continues to work full time. she and her partner are hoping to have children. Medical history is unremarkable, and she takes no medications. Colposcopy-directed biopsy of the cervix revealed Which of the following results can the patient reasonably squamous cell carcinoma with invasion to 6 mm in depth. expect with the new chemotherapy regimen? There is no radiographic evidence of pelvic or abdominal (A) Greater probability of cure adenopathy and no evidence of distant metastatic disease. (B) Improved quality of life (C) Longer life Which of the following is the most appropriate treatment? (D) Longer time without further cancer growth (A) Concurrent radiation therapy and cisplatin (B) Continuous progestin therapy

continues to work full time. she and her partner are hoping to have children. Medical history is unremarkable, and she takes no medications. Colposcopy-directed biopsy of the cervix revealed Which of the following results can the patient reasonably squamous cell carcinoma with invasion to 6 mm in depth. expect with the new chemotherapy regimen? There is no radiographic evidence of pelvic or abdominal (A) Greater probability of cure adenopathy and no evidence of distant metastatic disease. (B) Improved quality of life (C) Longer life Which of the following is the most appropriate treatment? (D) Longer time without further cancer growth (A) Concurrent radiation therapy and cisplatin (B) Continuous progestin therapy Item 48 (C) Fertility-preserving surgery (D) Hysterectomy and pelvic node dissection A 73-year-old woman is evaluated in the office follow- ing a diagnosis of right-sided breast cancer 2 months ago. The cancer was estrogen receptor-positive, progesterone Item 51 receptor-positive, and human epidermal growth factor A 56-year-old man is evaluated for increasing pain in the receptor 2-negative. She is asymptomatic and her only mid chest when swallowing. He has not experienced weight medications are anastrozole, vitamin D, and calcium. loss. Medical history is significant for longstanding gastro- On physical examination, prior right lumpectomy esophageal reflux disease. His only medication is over-the- and sentinel node sampling incisions are well-healed. The counter famotidine. remaining physical examination findings are unremark- On physical examination, vital signs are normal. A able. 3-cm, left supraclavicular lymph node is palpable. The liver edge is palpable 5 cm below the right costal margin. Which of the following is the most appropriate Contrast-enhanced CT scan demonstrates a thicken- management of this patient’s bone health? ing at the gastroesophageal junction and numerous hepatic metastases. The enlarged left supraclavicular node is also (A) Dual-energy x-ray absorptiometry screening noted. An upper endoscopy reveals a mass just above the gas- (B) Begin alendronate troesophageal junction, and biopsy shows adenocarcinoma. (C) Begin denosumab (D) Substitute raloxifene for anastrozole Which of the following is the most appropriate test to perform next?

Item 48 (C) Fertility-preserving surgery (D) Hysterectomy and pelvic node dissection A 73-year-old woman is evaluated in the office follow- ing a diagnosis of right-sided breast cancer 2 months ago. The cancer was estrogen receptor-positive, progesterone Item 51 receptor-positive, and human epidermal growth factor A 56-year-old man is evaluated for increasing pain in the receptor 2-negative. She is asymptomatic and her only mid chest when swallowing. He has not experienced weight medications are anastrozole, vitamin D, and calcium. loss. Medical history is significant for longstanding gastro- On physical examination, prior right lumpectomy esophageal reflux disease. His only medication is over-the- and sentinel node sampling incisions are well-healed. The counter famotidine. remaining physical examination findings are unremark- On physical examination, vital signs are normal. A able. 3-cm, left supraclavicular lymph node is palpable. The liver edge is palpable 5 cm below the right costal margin. Which of the following is the most appropriate Contrast-enhanced CT scan demonstrates a thicken- management of this patient’s bone health? ing at the gastroesophageal junction and numerous hepatic metastases. The enlarged left supraclavicular node is also (A) Dual-energy x-ray absorptiometry screening noted. An upper endoscopy reveals a mass just above the gas- (B) Begin alendronate troesophageal junction, and biopsy shows adenocarcinoma. (C) Begin denosumab (D) Substitute raloxifene for anastrozole Which of the following is the most appropriate test to perform next? Item 49 (A) Assess tumor for BRAF expression

Item 48 (C) Fertility-preserving surgery (D) Hysterectomy and pelvic node dissection A 73-year-old woman is evaluated in the office follow- ing a diagnosis of right-sided breast cancer 2 months ago. The cancer was estrogen receptor-positive, progesterone Item 51 receptor-positive, and human epidermal growth factor A 56-year-old man is evaluated for increasing pain in the receptor 2-negative. She is asymptomatic and her only mid chest when swallowing. He has not experienced weight medications are anastrozole, vitamin D, and calcium. loss. Medical history is significant for longstanding gastro- On physical examination, prior right lumpectomy esophageal reflux disease. His only medication is over-the- and sentinel node sampling incisions are well-healed. The counter famotidine. remaining physical examination findings are unremark- On physical examination, vital signs are normal. A able. 3-cm, left supraclavicular lymph node is palpable. The liver edge is palpable 5 cm below the right costal margin. Which of the following is the most appropriate Contrast-enhanced CT scan demonstrates a thicken- management of this patient’s bone health? ing at the gastroesophageal junction and numerous hepatic metastases. The enlarged left supraclavicular node is also (A) Dual-energy x-ray absorptiometry screening noted. An upper endoscopy reveals a mass just above the gas- (B) Begin alendronate troesophageal junction, and biopsy shows adenocarcinoma. (C) Begin denosumab (D) Substitute raloxifene for anastrozole Which of the following is the most appropriate test to perform next? Item 49 (A) Assess tumor for BRAF expression A 78-year-old man undergoes preoperative evaluation (B) Assess tumor for epidermal growth factor receptor for left knee arthroplasty. Other than knee pain, he has expression

Item 48 (C) Fertility-preserving surgery (D) Hysterectomy and pelvic node dissection A 73-year-old woman is evaluated in the office follow- ing a diagnosis of right-sided breast cancer 2 months ago. The cancer was estrogen receptor-positive, progesterone Item 51 receptor-positive, and human epidermal growth factor A 56-year-old man is evaluated for increasing pain in the receptor 2-negative. She is asymptomatic and her only mid chest when swallowing. He has not experienced weight medications are anastrozole, vitamin D, and calcium. loss. Medical history is significant for longstanding gastro- On physical examination, prior right lumpectomy esophageal reflux disease. His only medication is over-the- and sentinel node sampling incisions are well-healed. The counter famotidine. remaining physical examination findings are unremark- On physical examination, vital signs are normal. A able. 3-cm, left supraclavicular lymph node is palpable. The liver edge is palpable 5 cm below the right costal margin. Which of the following is the most appropriate Contrast-enhanced CT scan demonstrates a thicken- management of this patient’s bone health? ing at the gastroesophageal junction and numerous hepatic metastases. The enlarged left supraclavicular node is also (A) Dual-energy x-ray absorptiometry screening noted. An upper endoscopy reveals a mass just above the gas- (B) Begin alendronate troesophageal junction, and biopsy shows adenocarcinoma. (C) Begin denosumab (D) Substitute raloxifene for anastrozole Which of the following is the most appropriate test to perform next? Item 49 (A) Assess tumor for BRAF expression A 78-year-old man undergoes preoperative evaluation (B) Assess tumor for epidermal growth factor receptor for left knee arthroplasty. Other than knee pain, he has expression no other symptoms. Medical history is otherwise unre- (C) Assess tumor for human epidermal growth factor 2 markable. His only medication is ibuprofen, which he has amplification recently discontinued. (D) PET/CT

A 78-year-old man undergoes preoperative evaluation (B) Assess tumor for epidermal growth factor receptor for left knee arthroplasty. Other than knee pain, he has expression no other symptoms. Medical history is otherwise unre- (C) Assess tumor for human epidermal growth factor 2 markable. His only medication is ibuprofen, which he has amplification recently discontinued. (D) PET/CT 62

ntsc bet cH Item 52 Which of the following imaging studies should be i — performed next? = A 77-year-old woman undergoes follow-up evaluation for recently diagnosed stage I adenocarcinoma of the lung. (A) Contrast-enhanced CT of the chest, abdomen, and E wn Medical history is notable for very severe COPD that limits pelvis wn a her ability to dress unaided. Her medications are an inhaled (B) CT colonography wn wn corticosteroid, salmeterol, tiotropium, roflumilast, and an * -(C) Whole-body PET/CT ee albuterol inhaler as needed. (D) No additional imaging studies i) On physical examination, respiration rate is 25/min; rn

performed next? = A 77-year-old woman undergoes follow-up evaluation for recently diagnosed stage I adenocarcinoma of the lung. (A) Contrast-enhanced CT of the chest, abdomen, and E wn Medical history is notable for very severe COPD that limits pelvis wn a her ability to dress unaided. Her medications are an inhaled (B) CT colonography wn wn corticosteroid, salmeterol, tiotropium, roflumilast, and an * -(C) Whole-body PET/CT ee albuterol inhaler as needed. (D) No additional imaging studies i) On physical examination, respiration rate is 25/min; rn other vital signs are normal. Oxygen saturation is 91% breathing 3 L/min of oxygen by nasal cannula. BMI is 20, Item 55 and she is thin with significant muscle wasting. She has a prolonged expiratory phase of respiration and decreased A 66-year-old woman is evaluated following completion of breath sounds bilaterally. therapy for locally advanced squamous cell carcinoma of Surgical and pulmonary consults concur that the the hypopharynx. She was treated with combined cisplatin patient is too chronically disabled to safely undergo elective chemotherapy and irradiation. One month ago, imaging thoracic surgery. with PET/CT revealed a complete response. She is a former smoker with a 40-pack-year history who quit 7 years ago. Which of the following is the most appropriate treatment? She takes no medications. On physical examination, vital signs are normal. She (A ae Combination platinum-based chemotherapy has dry oral mucosa and post-irradiation induration to the (B Combined chemotherapy and radiation therapy right of the neck. No cervical adenopathy is noted. (Cc Se Immunotherapy Which of the following imaging tests is most appropriate? (Dwe, Stereotactic radiation therapy

other vital signs are normal. Oxygen saturation is 91% breathing 3 L/min of oxygen by nasal cannula. BMI is 20, Item 55 and she is thin with significant muscle wasting. She has a prolonged expiratory phase of respiration and decreased A 66-year-old woman is evaluated following completion of breath sounds bilaterally. therapy for locally advanced squamous cell carcinoma of Surgical and pulmonary consults concur that the the hypopharynx. She was treated with combined cisplatin patient is too chronically disabled to safely undergo elective chemotherapy and irradiation. One month ago, imaging thoracic surgery. with PET/CT revealed a complete response. She is a former smoker with a 40-pack-year history who quit 7 years ago. Which of the following is the most appropriate treatment? She takes no medications. On physical examination, vital signs are normal. She (A ae Combination platinum-based chemotherapy has dry oral mucosa and post-irradiation induration to the (B Combined chemotherapy and radiation therapy right of the neck. No cervical adenopathy is noted. (Cc Se Immunotherapy Which of the following imaging tests is most appropriate? (Dwe, Stereotactic radiation therapy (A) Low-dose CT of the chest in 1 year

other vital signs are normal. Oxygen saturation is 91% breathing 3 L/min of oxygen by nasal cannula. BMI is 20, Item 55 and she is thin with significant muscle wasting. She has a prolonged expiratory phase of respiration and decreased A 66-year-old woman is evaluated following completion of breath sounds bilaterally. therapy for locally advanced squamous cell carcinoma of Surgical and pulmonary consults concur that the the hypopharynx. She was treated with combined cisplatin patient is too chronically disabled to safely undergo elective chemotherapy and irradiation. One month ago, imaging thoracic surgery. with PET/CT revealed a complete response. She is a former smoker with a 40-pack-year history who quit 7 years ago. Which of the following is the most appropriate treatment? She takes no medications. On physical examination, vital signs are normal. She (A ae Combination platinum-based chemotherapy has dry oral mucosa and post-irradiation induration to the (B Combined chemotherapy and radiation therapy right of the neck. No cervical adenopathy is noted. (Cc Se Immunotherapy Which of the following imaging tests is most appropriate? (Dwe, Stereotactic radiation therapy (A) Low-dose CT of the chest in 1 year Item 53 ( _(B) MRIofthe neck in 3 months (C) PET/CT in 3 months A 34-year-old man is evaluated for increasing fatigue, con- stipation, and weight gain of several months’ duration. He (D) No additional imaging is required has no chest pain, palpitations, dyspnea, or edema. Medical history is significant for classic Hodgkin lymphoma treated with combination chemotherapy and involved site irra- Item 56 diation to the neck 7 years ago. He has been in complete A 53-year-old man is evaluated after recent surgery for remission since then. colon cancer. Family history is significant for a paternal On physical examination, blood pressure is 135/80 mm uncle with colon cancer at age 47 years and a paternal aunt Hg and pulse rate is 56/min. Other vital signs are normal. with a history of uterine cancer. There is a healed incision on his left mid neck. The remain- Postsurgical pathology results show poorly differenti- der of the examination is normal. ated T3N1 (stage IIIB) colon cancer.

Item 53 ( _(B) MRIofthe neck in 3 months (C) PET/CT in 3 months A 34-year-old man is evaluated for increasing fatigue, con- stipation, and weight gain of several months’ duration. He (D) No additional imaging is required has no chest pain, palpitations, dyspnea, or edema. Medical history is significant for classic Hodgkin lymphoma treated with combination chemotherapy and involved site irra- Item 56 diation to the neck 7 years ago. He has been in complete A 53-year-old man is evaluated after recent surgery for remission since then. colon cancer. Family history is significant for a paternal On physical examination, blood pressure is 135/80 mm uncle with colon cancer at age 47 years and a paternal aunt Hg and pulse rate is 56/min. Other vital signs are normal. with a history of uterine cancer. There is a healed incision on his left mid neck. The remain- Postsurgical pathology results show poorly differenti- der of the examination is normal. ated T3N1 (stage IIIB) colon cancer. Which of the following is the most appropriate test to Which of the following is the most appropriate test to perform next? perform next? (A) CT of neck, chest, abdomen, and pelvis (A) BRAF mutational analysis (B) Echocardiogram (B) Epidermal growth factor receptor mutational analysis (C) PET/CT (C) KRAS mutational analysis (D) Thyroid-stimulating hormone measurement (D) Mismatch repair protein expression (E) Thyroid ultrasound

(A) CT of neck, chest, abdomen, and pelvis (A) BRAF mutational analysis (B) Echocardiogram (B) Epidermal growth factor receptor mutational analysis (C) PET/CT (C) KRAS mutational analysis (D) Thyroid-stimulating hormone measurement (D) Mismatch repair protein expression (E) Thyroid ultrasound Item 57 Item 54 A 53-year-old man is evaluated in the office following A 61-year-old woman is evaluated following a diagnosis hemicolectomy for adenocarcinoma of the colon. He is of colon cancer. A colonoscopy performed for iron defi- otherwise healthy, has no symptoms, and takes no med- ciency anemia revealed an adenocarcinoma at the splenic ications. flexure. The patient is asymptomatic and otherwise has Physical examinationis normal. no medical problems. Oral iron replacement therapy has Presurgical contrast-enhanced CT scan of the teat, been initiated. abdomen, and pelvis was negative for metastases.’ On physical examination, vital signs are normal, and Pathology revealed a 4-cm adenocarcinoma that was the remainder of the examination is noncontributory. poorly differentiated and invading into the submucosa Results of laboratory studies show a hemoglobin level but not into the muscularis. All 17 lymph nodes sampled of 9.9 g/dL (99 g/L). A comprehensive metabolic profile and were negative for tumor. The tumor is staged as T2NO carcinoembryonic antigen measurement are within normal (stage I). The tumor is negative for KRAS, NRAS, and BRAF limits. mutations. 63

Self-Assessment Test 17) = =A Which of the following is the most important prognostic Item 60 > factor? n A 62-year-old woman is evaluated in the office following a wn oO =. Degree of tumor differentiation diagnosis of atypical ductal hyperplasia. She underwent a wn 72) right total hip replacement 2 years ago complicated by deep 3 KRAS, NRAS, and BRAF tumor mutational status @ venous thrombosis. Medical history is otherwise unremark- = Performance status of patient ~~ able, and she takes no medications. = Size of the tumor On physical examination, vital signs are normal. There @ wn ad i=) Stage of the tumor is a well-healed left breast incision with no skin changes and no palpable mass or nodule.

17) = =A Which of the following is the most important prognostic Item 60 > factor? n A 62-year-old woman is evaluated in the office following a wn oO =. Degree of tumor differentiation diagnosis of atypical ductal hyperplasia. She underwent a wn 72) right total hip replacement 2 years ago complicated by deep 3 KRAS, NRAS, and BRAF tumor mutational status @ venous thrombosis. Medical history is otherwise unremark- = Performance status of patient ~~ able, and she takes no medications. = Size of the tumor On physical examination, vital signs are normal. There @ wn ad i=) Stage of the tumor is a well-healed left breast incision with no skin changes and no palpable mass or nodule. Item 58 Which of the following is the most appropriate breast A 51-year-old man is evaluated for intermittent, bright red cancer chemoprevention for this patient? blood per rectum of 10 weeks’ duration. Medical history is (A) Aspirin otherwise unremarkable, and he takes no medications. On physical examination, vital signs are normal. Digi- (B) Exemestane tal rectal examination is normal. (C) Raloxifene Stool is positive for fecal occult blood. (D) Tamoxifen A colonoscopy is performed, and a nonobstructing lesion is noted at 10 cm from the anal verge. Examination of the rest of the colon is unremarkable. An MRI scan of Item 61 the rectum shows the lesion to be invading into but not through the full thickness of the muscularis. No abnor- A 48-year-old woman is evaluated following the diagnosis

Item 58 Which of the following is the most appropriate breast A 51-year-old man is evaluated for intermittent, bright red cancer chemoprevention for this patient? blood per rectum of 10 weeks’ duration. Medical history is (A) Aspirin otherwise unremarkable, and he takes no medications. On physical examination, vital signs are normal. Digi- (B) Exemestane tal rectal examination is normal. (C) Raloxifene Stool is positive for fecal occult blood. (D) Tamoxifen A colonoscopy is performed, and a nonobstructing lesion is noted at 10 cm from the anal verge. Examination of the rest of the colon is unremarkable. An MRI scan of Item 61 the rectum shows the lesion to be invading into but not through the full thickness of the muscularis. No abnor- A 48-year-old woman is evaluated following the diagnosis mal lymph nodes are seen on MRI. Contrast-enhanced CT of a metastatic neuroendocrine tumor. Two weeks ago, she scan of the chest and abdomen does not show evidence of underwent ultrasonography for biliary colic, which unex- metastases. pectedly showed multiple hepatic lesions. Gallstones were

mal lymph nodes are seen on MRI. Contrast-enhanced CT of a metastatic neuroendocrine tumor. Two weeks ago, she scan of the chest and abdomen does not show evidence of underwent ultrasonography for biliary colic, which unex- metastases. pectedly showed multiple hepatic lesions. Gallstones were Biopsy of the mass shows adenocarcinoma. not present. A subsequent contrast-enhanced CT scan of the abdomen demonstrated multiple hypodense lesions in the liver consistent with metastatic disease. A needle Which of the following is the most appropriate treatment? biopsy of a liver lesion showed a well-differentiated, low- (A) Chemotherapy grade neuroendocrine tumor with only very rare mitotic (B) Irradiation plus chemotherapy figures. Medical history is otherwise unremarkable. The patient feels well without any symptoms, and she takes no (C) Irradiation, chemotherapy, and surgery medications. (D) Surgery On physical examination, vital signs are normal. Abdominal examination reveals a palpable, firm liver edge 5 cm below the right costal margin. Item 59 Results of laboratory studies show a minor elevation of A 68-year-old man is evaluated for shortness of breath, transaminases and alkaline phosphatase. headache, and swelling of the neck. He first noticed symp- toms 3 weeks ago, which have worsened over the past Which of the following is the most appropriate 2 days. management? Medical history is significant for a 25-pack-year history of smoking. (A) Hepatic artery embolization On physical examination, temperature is 36.5 °C (97.8 °F), (B) Hormonal therapy with a somatostatin analogue blood pressure is 110/65 mm Hg, pulse rate is 112/min, (C) Peptide-receptor radiotherapy and respiration rate is 18/min. Oxygen saturation is 92% (D) Repeat imaging in 3 months breathing ambient air. The patient is cachectic but appears comfortable. His face is plethoric, and there are distended (E) Systemic chemotherapy cutaneous vessels over the anterior thorax. An enlarged right supraclavicular lymph node is palpable. Pulmonary examination is normal. Item 62 CT scan of the chest reveals bulky mediastinal adenop- A 72-year-old woman is evaluated for rectal bleeding with athy compressing the superior vena cava, right supraclavic- bowel movements. ular adenopathy, and a small right-sided pleural effusion. On physical examination, vital signs are normal, and the remainder of the examination, including digital rectal Which of the following is the most appropriate examination, is unremarkable. management? A colonoscopy is performed, and a bulky lesion is noted 10 cm from the anal verge. The rest of the colonoscopy (A) Biopsy of the supraclavicular node results are normal. (B) Glucocorticoids MRI of the pelvis shows a bulky tumor in the upper (C) Radiation therapy third of the rectum, involving the full thickness of the rectal (D) Surgical resection of the mediastinal lymphadenopathy wall, and several enlarged mesorectal lymph nodes of up to

Biopsy of the mass shows adenocarcinoma. not present. A subsequent contrast-enhanced CT scan of the abdomen demonstrated multiple hypodense lesions in the liver consistent with metastatic disease. A needle Which of the following is the most appropriate treatment? biopsy of a liver lesion showed a well-differentiated, low- (A) Chemotherapy grade neuroendocrine tumor with only very rare mitotic (B) Irradiation plus chemotherapy figures. Medical history is otherwise unremarkable. The patient feels well without any symptoms, and she takes no (C) Irradiation, chemotherapy, and surgery medications. (D) Surgery On physical examination, vital signs are normal. Abdominal examination reveals a palpable, firm liver edge 5 cm below the right costal margin. Item 59 Results of laboratory studies show a minor elevation of A 68-year-old man is evaluated for shortness of breath, transaminases and alkaline phosphatase. headache, and swelling of the neck. He first noticed symp- toms 3 weeks ago, which have worsened over the past Which of the following is the most appropriate 2 days. management? Medical history is significant for a 25-pack-year history of smoking. (A) Hepatic artery embolization On physical examination, temperature is 36.5 °C (97.8 °F), (B) Hormonal therapy with a somatostatin analogue blood pressure is 110/65 mm Hg, pulse rate is 112/min, (C) Peptide-receptor radiotherapy and respiration rate is 18/min. Oxygen saturation is 92% (D) Repeat imaging in 3 months breathing ambient air. The patient is cachectic but appears comfortable. His face is plethoric, and there are distended (E) Systemic chemotherapy cutaneous vessels over the anterior thorax. An enlarged right supraclavicular lymph node is palpable. Pulmonary examination is normal. Item 62 CT scan of the chest reveals bulky mediastinal adenop- A 72-year-old woman is evaluated for rectal bleeding with athy compressing the superior vena cava, right supraclavic- bowel movements. ular adenopathy, and a small right-sided pleural effusion. On physical examination, vital signs are normal, and the remainder of the examination, including digital rectal Which of the following is the most appropriate examination, is unremarkable. management? A colonoscopy is performed, and a bulky lesion is noted 10 cm from the anal verge. The rest of the colonoscopy (A) Biopsy of the supraclavicular node results are normal. (B) Glucocorticoids MRI of the pelvis shows a bulky tumor in the upper (C) Radiation therapy third of the rectum, involving the full thickness of the rectal (D) Surgical resection of the mediastinal lymphadenopathy wall, and several enlarged mesorectal lymph nodes of up to 64

| Self-Assessment Test — cH 2 cm in diameter are noted. CT scan of the chest and abdo- (C) Polycythemia vera i ad men is normal. (D) Relative erythrocytosis i A biopsy of the mass shows adenocarcinoma. (E) Renal cell carcinoma 5 wn 72) Which of the following is the most appropriate @ w treatment? w Item 65 = P= (A) Chemotherapy followed by irradiation and then A 62-year-old woman is evaluated for left lower pelvic pain a 172) surgery for the last 3 months. Family history is significant for ovar- (B) Surgery alone ian cancer in her mother at age 51 years and triple-negative breast cancer in her sister at age 42 years. (C) SS Surgery followed by irradiation On physical examination, vital signs are normal. Pelvic (D) Surgery followed by irradiation and then chemo- examination is notable for a left adnexal mass. therapy Results of laboratory studies show a CA-125 level of 135 U/mL (normal, <20 U/mL). Complete blood count and liver chemistry test results are normal. Item 63 CT scan of the chest, abdomen, and pelvis reveals an A 61-year-old man is evaluated in the emergency depart 8-cm left adnexal mass. There is no evidence of abdominal ment for chronic low back pain, which has worsened rapidly or pelvic adenopathy or distant metastases. over the past week and is now associated with new-onset weakness in his legs. Medical history includes metastatic Which of the following is the most appropriate initial non-small cell carcinoma of the lung. Previous to this event, management? the patient had good functional status. (A) BRCA1/2 testing On physical examination, vital signs are normal. He has 4/5 muscle strength with flexion at the bilateral hips (B) CT-guided biopsy of the mass and knees. (C) Neoadjuvant chemotherapy MRI of the entire spine reveals a 5-cm mass centered in (D) Surgical removal of the mass the posterior elements of L1 and L2 with extension into the epidural space and spinal cord compression.

ad men is normal. (D) Relative erythrocytosis i A biopsy of the mass shows adenocarcinoma. (E) Renal cell carcinoma 5 wn 72) Which of the following is the most appropriate @ w treatment? w Item 65 = P= (A) Chemotherapy followed by irradiation and then A 62-year-old woman is evaluated for left lower pelvic pain a 172) surgery for the last 3 months. Family history is significant for ovar- (B) Surgery alone ian cancer in her mother at age 51 years and triple-negative breast cancer in her sister at age 42 years. (C) SS Surgery followed by irradiation On physical examination, vital signs are normal. Pelvic (D) Surgery followed by irradiation and then chemo- examination is notable for a left adnexal mass. therapy Results of laboratory studies show a CA-125 level of 135 U/mL (normal, <20 U/mL). Complete blood count and liver chemistry test results are normal. Item 63 CT scan of the chest, abdomen, and pelvis reveals an A 61-year-old man is evaluated in the emergency depart 8-cm left adnexal mass. There is no evidence of abdominal ment for chronic low back pain, which has worsened rapidly or pelvic adenopathy or distant metastases. over the past week and is now associated with new-onset weakness in his legs. Medical history includes metastatic Which of the following is the most appropriate initial non-small cell carcinoma of the lung. Previous to this event, management? the patient had good functional status. (A) BRCA1/2 testing On physical examination, vital signs are normal. He has 4/5 muscle strength with flexion at the bilateral hips (B) CT-guided biopsy of the mass and knees. (C) Neoadjuvant chemotherapy MRI of the entire spine reveals a 5-cm mass centered in (D) Surgical removal of the mass the posterior elements of L1 and L2 with extension into the epidural space and spinal cord compression. Item 66 Which of the following is the most appropriate treatment A 48-year-old man is evaluated for an asymptomatic neck for this patient? mass that developed 3 weeks ago. Medical history is unre- (A) Dexamethasone markable, and he takes no medications. (B) Dexamethasone, surgical resection, and irradiation On physical examination, vital signs are normal. There is a 2-cm firm, fixed, and nontender mass on the right side (C) Irradiation of his neck. (D) Surgical resection Results of laboratory studies are within normal limits. CT of the neck reveals a 2-cm partially cystic neck mass Item 64 on the right side with suggestion of invasion into surround-

Item 66 Which of the following is the most appropriate treatment A 48-year-old man is evaluated for an asymptomatic neck for this patient? mass that developed 3 weeks ago. Medical history is unre- (A) Dexamethasone markable, and he takes no medications. (B) Dexamethasone, surgical resection, and irradiation On physical examination, vital signs are normal. There is a 2-cm firm, fixed, and nontender mass on the right side (C) Irradiation of his neck. (D) Surgical resection Results of laboratory studies are within normal limits. CT of the neck reveals a 2-cm partially cystic neck mass Item 64 on the right side with suggestion of invasion into surround- A 60-year-old woman is evaluated for right-sided mid back ing tissue. pain of 2 months’ duration. Medical history is significant for hypertension treated with hydrochlorothiazide. She takes Which of the following is the most appropriate initial no other medications. management? On physical examination, vital signs are within normal (A) Fine-needle aspiration limits. Oxygen saturation is 99% with the patient breathing ambient air. The remainder of the examination is normal. (B) Observation for 1 month

A 60-year-old woman is evaluated for right-sided mid back ing tissue. pain of 2 months’ duration. Medical history is significant for hypertension treated with hydrochlorothiazide. She takes Which of the following is the most appropriate initial no other medications. management? On physical examination, vital signs are within normal (A) Fine-needle aspiration limits. Oxygen saturation is 99% with the patient breathing ambient air. The remainder of the examination is normal. (B) Observation for 1 month Laboratory studies: (C) PET/CT Hemoglobin 20 g/dL (200 g/L) (D) Removal of the mass Leukocyte count 7200/uL (7.2 x109/L) Platelet count 295,000/uL (295 x 109/L) Urinalysis 3+ blood; no protein; 30 erythrocytes/ Item 67 hpf; no casts or dysmorphic A 70-year-old woman undergoes consultation following erythrocytes a diagnosis of breast cancer. She has no other medical Subsequent measurement of erythropoietin level was conditions. 180 mU/mL (180 U/L). Core biopsy of a left breast mass revealed grade III, estrogen receptor—positive, progesterone receptor—positive, Which of the following is the most likely diagnosis? and human epidermal growth factor receptor 2—positive invasive ductal carcinoma. Left lumpectomy revealed inva- (A) Lung cancer sive ductal carcinoma measuring 1.9 cm in size. Two senti- (B) Myelodysplastic syndrome nel nodes were negative. 65

Self-Assessment Test rn 2. = Which of the following is the most appropriate adjuvant multiple areas of her right breast. A biopsy showed estro- ps treatment or management for this patient? gen receptor-positive ductal carcinoma in situ with high wn wn nuclear grade. She underwent a bilateral mastectomy and oO 7) (A) Chemotherapy and anti-human epidermal growth a right sentinel node biopsy, which revealed ductal carci- ) factor receptor 2-antibody, breast irradiation, and =} noma in situ of the right breast and two negative sentinel © endocrine therapy s nodes. =r Endocrine therapy On physical examination, there are healing bilateral o wn Obtain a gene expression profile mastectomy incisions with tissue expanders in place. ~~ Sos Radiation therapy followed by endocrine therapy Which of the following is the most appropriate next treatment for this patient? Item 68 (A) Anastrozole A 72-year-old man was diagnosed 9 years ago with prostate (B) Radiation therapy cancer. After radiation treatment, his prostate-specific antigen (PSA) level dropped to a nadir of 1.5 ng/mL (1.5 ug/L); it had (C) Tamoxifen remained stable until it rose to 2 ng/mL (2 ug/L) 1 year ago and (D) No adjuvant treatment is currently 3.2 ng/mL (3.2 ug/L). He has no symptoms. Medical history is unremarkable, and he takes no medications. Vital signs and all other physical examination findings Item 71 are normal. Results of all other laboratory studies are within A 55-year-old woman is evaluated in the office following normal limits. treatment for limited-stage small cell lung cancer. She was Biopsy of the prostate is negative. CT of the chest, abdo- treated with cisplatin/etoposide chemotherapy plus irra- men, and pelvis and bone scan are negative for metastatic diation to the site of the primary tumor. Repeat imaging disease. at the end of treatment showed complete response. She is currently asymptomatic. Which of the following is the most appropriate management? Which of the following is the most appropriate management? (A) Androgen deprivation therapy (B) Chemotherapy (A) Maintenance chemotherapy (C) Cryotherapy (B) PET/CT in 6 months (D) Monitor PSA level without treatment (C) Prophylactic cranial irradiation (D) Repeat bronchoscopy

Self-Assessment Test rn 2. = Which of the following is the most appropriate adjuvant multiple areas of her right breast. A biopsy showed estro- ps treatment or management for this patient? gen receptor-positive ductal carcinoma in situ with high wn wn nuclear grade. She underwent a bilateral mastectomy and oO 7) (A) Chemotherapy and anti-human epidermal growth a right sentinel node biopsy, which revealed ductal carci- ) factor receptor 2-antibody, breast irradiation, and =} noma in situ of the right breast and two negative sentinel © endocrine therapy s nodes. =r Endocrine therapy On physical examination, there are healing bilateral o wn Obtain a gene expression profile mastectomy incisions with tissue expanders in place. ~~ Sos Radiation therapy followed by endocrine therapy Which of the following is the most appropriate next treatment for this patient? Item 68 (A) Anastrozole A 72-year-old man was diagnosed 9 years ago with prostate (B) Radiation therapy cancer. After radiation treatment, his prostate-specific antigen (PSA) level dropped to a nadir of 1.5 ng/mL (1.5 ug/L); it had (C) Tamoxifen remained stable until it rose to 2 ng/mL (2 ug/L) 1 year ago and (D) No adjuvant treatment is currently 3.2 ng/mL (3.2 ug/L). He has no symptoms. Medical history is unremarkable, and he takes no medications. Vital signs and all other physical examination findings Item 71 are normal. Results of all other laboratory studies are within A 55-year-old woman is evaluated in the office following normal limits. treatment for limited-stage small cell lung cancer. She was Biopsy of the prostate is negative. CT of the chest, abdo- treated with cisplatin/etoposide chemotherapy plus irra- men, and pelvis and bone scan are negative for metastatic diation to the site of the primary tumor. Repeat imaging disease. at the end of treatment showed complete response. She is currently asymptomatic. Which of the following is the most appropriate management? Which of the following is the most appropriate management? (A) Androgen deprivation therapy (B) Chemotherapy (A) Maintenance chemotherapy (C) Cryotherapy (B) PET/CT in 6 months (D) Monitor PSA level without treatment (C) Prophylactic cranial irradiation (D) Repeat bronchoscopy Item 69 A 47-year-old man is evaluated during a follow-up exam- Item 72 ination. His medical history is significant for resection of A 37-year-old woman is seen for follow-up evaluation cutaneous malignant melanoma from his left upper back 6 months after resection of cutaneous melanoma. It had 4 years ago. One month ago, he was diagnosed with metastatic a 0.45-mm depth of invasion by Breslow microstaging melanoma to the liver and lungs. He takes no medications. (stage IA). No mutation in the liver metastasis BRAF gene was On physical examination, vital signs are normal. There identified. is a healed incision on the right thigh from resection of the melanoma. There is no evidence of cutaneous or in-transit Which of the following is the most appropriate treatment recurrence and no femoral or inguinal adenopathy. for this patient? Which of the following is the most appropriate cancer (A) Anti-CTLA-4 antibody plus anti-programmed death surveillance for this patient? antibody (B) BRAF inhibitor (A) Annual chest radiograph

Item 69 A 47-year-old man is evaluated during a follow-up exam- Item 72 ination. His medical history is significant for resection of A 37-year-old woman is seen for follow-up evaluation cutaneous malignant melanoma from his left upper back 6 months after resection of cutaneous melanoma. It had 4 years ago. One month ago, he was diagnosed with metastatic a 0.45-mm depth of invasion by Breslow microstaging melanoma to the liver and lungs. He takes no medications. (stage IA). No mutation in the liver metastasis BRAF gene was On physical examination, vital signs are normal. There identified. is a healed incision on the right thigh from resection of the melanoma. There is no evidence of cutaneous or in-transit Which of the following is the most appropriate treatment recurrence and no femoral or inguinal adenopathy. for this patient? Which of the following is the most appropriate cancer (A) Anti-CTLA-4 antibody plus anti-programmed death surveillance for this patient? antibody (B) BRAF inhibitor (A) Annual chest radiograph (C) Combination of a BRAF and MEK inhibitor (B) Brain MRI every 6 months for 3 years; PET/CT annu- ally for 5 years (D) MEK inhibitor (C) Complete blood count, biochemistry profile, and lac- tate dehydrogenase measurement every 6 months Item 70 (D) Physical examination and dermatologic evaluation ‘A 54-year-old postmenopausal woman had an abnormal every 6 months screening mammogram that revealed new calcifications in (E) PET/CT annually for 5 years 66